Effects of ketorolac tromethamine mouthrinse (0.1%) on crevicular fluid prostaglandin E2 concentrations in untreated chronic periodontitis

Do NSAIDs used prior to standard inferior alveolar nerve blocks improve the analgesia of mandibular molars with irreversible pulpitis? An umbrella review

INTRODUCTION

The aim of the present umbrella review was to answer the following question: "Does the use of NSAIDs as premedication increase the efficacy of the standard inferior alveolar nerve block on teeth with symptomatic irreversible pulpitis?"

MATERIAL AND METHODS

Systematic reviews with and without meta-analyses that evaluated the influence of premedication on anesthetic efficacy of the inferior alveolar nerve in symptomatic irreversible pulpitis of mandibular molars were searched in six electronic databases (MEDLINE/PubMed, Scopus, Web of Science, Cochrane Library, EMBASE, and Grey Literature Reports), without the restriction of language or year of publication. A Measurement Tool to Assess systematic Reviews (AMSTAR 2) was used to evaluate the quality of the included studies.

RESULTS

Twelve systematic reviews were included. Only one did not perform a meta-analysis. The AMSTAR 2 overall confidence ranged from very low to high. In general, the main findings of the systematic reviews were that non-steroidal anti-inflammatory drugs (e.g., ibuprofen, oxicam, diclofenac, association of ibuprofen with acetaminophen, and ketorolac) increased the success rate of the inferior alveolar nerve block.

CONCLUSIONS

From the "very low" to "high"-quality evidence available, this umbrella review concluded that NSAIDs as premedication acts through cyclooxygenase pathways and block the synthesis of specific prostaglandins that complicate the mechanism of action of the anesthesia, improving its success rate.

CLINICAL RELEVANCE

Non-steroidal anti-inflammatory drugs can increase the success rate of the anesthetic technique of inferior alveolar nerve block efficacy in situations of mandibular molars with symptomatic irreversible pulpitis.

The Effects of Prednisone/Ketoprofen Administration in Association with Amoxicillin Clavulanate Following Periodontal Surgical Therapy in Patients with Severe Chronic Periodontitis

Background and Objectives: The aim of this study was to evaluate and compare the effects of two different anti-inflammatory drugs (ketoprofen and prednisone) combined with an antibiotic (amoxicillin + clavulanic acid) and periodontal surgery on dental and periodontal parameters in patients with severe chronic periodontitis. In addition, salivary stress expressed by cortisol levels was assessed. Materials and Methods: An interventional study was performed on 22 periodontal subjects and 19 clinical healthy controls. The patients were divided in four groups, depending on treatment planning, as follows: eight patients received prednisone and antibiotherapy, associated with surgical periodontal therapy; seven patients received ketoprofen and antibiotherapy, associated with surgical periodontal therapy (group II); seven patients received only prednisone. Periodontal healthy patients underwent routine scaling and polishing. Bleeding on probing (BOP), dental mobility and salivary cortisol (ng/mL) were assessed before and after treatment. The means and standard deviations for the salivary cortisol levels (SCLs), dental and periodontal parameters were calculated for all groups using each patient as a unit of analysis. Results: Data analyses showed that the two different anti-inflammatory drugs associated with or without surgical therapy were efficient on inflammation periodontal parameters (BOP, dental mobility). Prednisone treatment alone was associated with a significant decrease of SCLs between pretreatment and post-treatment. Conclusions: In the present study, the effects of either of the anti-inflammatory drugs on inflammation evolution and salivary stress were comparable in patients undergoing antibiotherapy and surgical periodontal therapy.

Adverse events associated with home use of mouthrinses: a systematic review

Background

Poor oral hygiene is strongly associated with oral and systemic diseases. Alongside mechanical tooth cleaning, the adjunctive use of mouthrinses has been widely advocated. Although research on the efficacy of various mouthrinse formulations is very active, there are a lack of conclusive data regarding their adverse effects.

Methods

We undertook a systematic review in accordance wih PRISMA guidelines of electronic databases of clinical trials of any duration with daily home use of mouthwashes, presenting clinical and subjective side effects (PROSPERO registration: CRD42016054037).

Results

After evaluating 614 titles and abstracts, 154 studies were selected for full-text analysis; 85 final papers were included. Based on the active ingredient in the test product, nine categories were created: cetyl pyridinium chloride, essential oils, chlorhexidine, triclosan, natural products, diclofenac, fluorides, delmopinol, and miscellaneous active substances. Most of the studies were of short duration (less than 6 months) with a defective 'methods' description; the reporting of adverse events often being overlooked. Both local morphological (oral mucosa and dental-crown staining, mucosal lesions) and functional (taste modifications, abnormal oral sensation) alterations were reported. Tooth staining was the most commonly listed adverse event, but it was quantitatively assessed only in a very small number of papers; most studies relied on patient reports. Staining was time associated; the longer the study, the higher its reported incidence and severity.

Conclusions

The reduced report of side effects may partly be due to a lack of an objective measure and lack of general guidelines that demand studies report their adverse events. The most frequently reported adverse effect was teeth staining. As in most studies, the effect was associated with trial duration; clinical trials should be of sufficient duration. New investigations meeting the suggested criteria of a minimal duration of 6 months should be planned.

Clinical and biochemical efficacy of minocycline in nonsurgical periodontal therapy: a randomized controlled pilot study

The present study evaluated the effects of systemic minocycline on clinical and biochemical parameters of chronic periodontitis, which is a common inflammatory disorder of the periodontium initiated by the presence of bacteria in the gingival sulcus. Besides nonsurgical periodontal therapy, 20 individuals received minocycline systemically while another 20 subjects received placebo capsules for 2 weeks. Plaque index (PI), sulcus bleeding index (SBI), probing depth (PD), and relative attachment level (RAL) were measured and gingival crevicular fluid (GCF) samples were obtained at baseline and first, third, and sixth months. Matrix metalloproteinase-8 (MMP-8) and prostaglandin E₂ (PGE₂) levels were analyzed by enzyme immunoassay method. Significant improvements in all parameters in both groups were recorded. In the minocycline group, changes in PI and SBI were significantly greater only at first month, whereas reductions in PD, RAL, MMP-8, and PGE₂ levels were greater at all times. MMP-8 and PGE₂ exhibited positive correlations with SBI, PD, and each other. Minocycline demonstrated clinical benefit for periodontal therapy and provided further improvements on inflammatory mediators promising a host-modulating capacity.

Accumulation of topical naproxen by cultured oral epithelium

Topically administered non-steroidal anti-inflammatory drugs (NSAIDs) inhibit periodontal bone loss, but little is known about the mechanism by which they penetrate oral epithelium. Active transporters could potentially play a role in this process. In this study, we used a cell line derived from oral epithelium to investigate a role for transporters and to characterize conditions that enhance epithelial penetration. Using fluorescence to monitor uptake, we demonstrated that SCC-25 cell monolayers transport naproxen with a Michaelis constant (K(m)) and maximum velocity (V(max)) of 164 microg/mL and 0.94 ng/min/microg protein, respectively. At steady state, the intra-cellular/extracellular concentration ratio was 3.4. Naproxen accumulation was more efficient at acidic pH than under neutral or alkaline conditions. Small proportions of glycerol, Pluronic F-127, and glucosylceramide enhanced naproxen entry. The individual and combined effects of glycerol and Pluronic F-127 were of lesser magnitude than those obtained with glucosylceramide or at pH 6.3. Thus, SCC-25 cells possess transporters for naproxen.

Host response modulation in the management of periodontal diseases

OBJECTIVE

To review the biological mechanisms and clinical utility of therapeutic modulation of the host response in the management of periodontal diseases.

MATERIAL AND METHODS

A search of MEDLINE-PubMed was performed up to and including December 2004. The search was limited to in vitro, experimental animal and clinical studies published in English. The selection criteria included all levels of available evidence: systematic reviews, randomised-controlled clinical trials, controlled clinical trials, prospective and retrospective cohort studies and case reports of human and experimental animal studies.

RESULTS

Six targets for non-microbial chemotherapeutic intervention were identified. Clinical trials have demonstrated the ability of non-steroidal anti-inflammatory drugs to slow periodontal disease progression. However, recently reported serious adverse effects preclude the use of cyclooxygenase-2 inhibitors as an adjunct to periodontal therapy. Adjunctive use of subantimicrobial dose doxycycline to non-surgical periodontal therapy is beneficial in the management of chronic periodontitis over 12 months. Controversial data exist on the effects of bisphosphonate administration as an adjunct to periodontal therapy. Evidence on modulation of other host mediators including lipoxins, cytokines and nitric oxide synthase is limited to animal research.

CONCLUSION

After validation in long-term clinical trials, adjunctive host modulation therapy may prove advantageous in the management of periodontal diseases.

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.

The effects of periodontal therapy on intracrevicular prostaglandin E2 concentrations and clinical parameters in pregnancy

BACKGROUND

The increase in circulating levels of progesterone during pregnancy stimulates production of prostaglandins, especially prostaglandin E2, possibly resulting in pregnancy gingivitis. The purpose of this study is to evaluate the influence of prostaglandin E2 concentrations on gingival tissues in pregnancy and to assess its relationship to clinical parameters.

METHODS

This study evaluates the effects of periodontal treatment on clinical indices including plaque index, gingival index, probing depth, and gingival crevicular fluid prostaglandin E2 levels of 22 pregnant women in their first, second, and third trimesters. Initial periodontal therapy consisting of scaling, root planing, and oral hygiene instruction was performed at the beginning of the first trimester and repeated each trimester. Prostaglandin E2 concentrations in gingival crevicular fluid were determined using a commercially available enzyme immunoassay kit. The statistical tests used were paired sample test and correlation analysis.

RESULTS

The results of the study show that periodontal therapy has resulted in an improvement in clinical parameters (P<0.05). There is also a statistically significant decrease in levels of prostaglandin E2 at the second and third trimesters following periodontal therapy (P <0.001). The correlation between prostaglandin E2 concentrations and clinical parameters is found to be non-significant (P >0.05).

CONCLUSIONS

Our data indicate that levels of prostaglandin E2 in gingival crevicular fluid may be used as a marker of gingival inflammation in order to determine the effects of periodontal therapy in pregnancy. Periodontal therapy that is performed throughout the entire pregnancy period may help prevent the threat of pregnancy gingivitis.

Prostaglandin E2 concentrations in gingival crevicular fluid: observations in untreated chronic periodontitis

OBJECTIVES

We set out to monitor gingival crevicular fluid prostaglandin E2 (GCF-PGE2) concentrations longitudinally in a cohort of subjects with chronic periodontitis, given that we had noted an unexplained trend for GCF-PGE2 concentrations to gradually increase in control groups and placebo populations in previously published clinical trials.

MATERIAL AND METHODS

41 adults with moderate-severe chronic periodontitis were recruited. GCF samples were collected from 8 test sites (with 5-8 mm probing depths and attachment loss) every 30 days for 150 days, and assayed for PGE2. Clinical measurements (probing depths, attachment levels, bleeding on probing) were recorded at days 0 and 150.

RESULTS

A gradual and statistically significant increase in GCF-PGE2 concentrations was observed over the course of the study, from 40.3 ng/ml to 83.1 ng/ml (p<0.001). When data were expressed as absolute PGE2 content, a similar statistically significant increase from baseline to day 150 was observed (p<0.001). GCF volumes did not vary significantly during the study (p>0.05). Over the same time period, no statistically significant changes in clinical parameters were recorded, with the exception of mean probing depths, which decreased slightly from 5.73 mm to 5.51 mm (p<0.05).

CONCLUSION

A trend for gradually increasing GCF-PGE2 concentrations in the absence of any clinical signs of disease progression was noted in a group of patients monitored longitudinally. We suggest that this phenomenon is to be expected in longitudinal clinical trials, and propose a new model for the role of PGE2 in the pathogenesis of periodontal destruction. We feel that if GCF mediators are to be monitored in clinical studies, then both concentrations and absolute mediator content should be calculated, and a standardised sampling protocol should be employed.

Soluble antagonists to interleukin-1 (IL-1) and tumor necrosis factor (TNF) inhibits loss of tissue attachment in experimental periodontitis

BACKGROUND, AIMS

Periodontal disease is a significant cause of tooth loss among adults and is characterized by the alteration and permanent destruction of the deeper periodontal tissues. Although the presence of pathologic microbes is required to trigger this process, the amplification and progression of the diseased state is believed to rely heavily on the production of host mediators in response to bacteria or their metabolic products. The inflammatory response is effective in preventing large-scale colonization of the gingival tissues by bacteria that lie in close proximity to the tooth surface or within the gingival sulcus. It has been postulated that the host-response in some individuals may lead to an over-reaction to invading oral pathogens resulting in the destruction of periodontal tissues.

METHODS

Several host-derived mediators are believed to contribute to this response. Two agents considered to be essential in periodontal destruction are interleukin-1 (IL-1) and tumor necrosis factor (TNF). We investigated the role of IL-1 and TNF in the loss of connective tissue attachment in a Macaca fascicularis primate model of experimental periodontitis. Silk ligatures impregnated with the periodontal pathogen, Porphyromonas gingivalis were wrapped around the posterior teeth and the activity of IL-1 and TNF were inhibited by soluble receptors to these proinflammatory cytokines via local injection into interdental papillae.

RESULTS

Histomorphometric analysis indicates that IL-1 and TNF antagonists significantly reduced the loss of connective tissue attachment by approximately 51% and the loss of alveolar bone height by almost 91%, both of which were statistically significant.

CONCLUSION

This investigation demonstrates that the loss of connective tissue attachment and progression of periodontal disease can be retarded by antagonists to specific host mediators such as IL-1 and TNF and may provide a potential treatment modality to combat the disease process.

Crevicular fluid prostaglandin E2 levels in periodontitis-resistant and periodontitis-susceptible adults

The aim of this cross-sectional study was to determine concentrations of prostaglandin E2 (PGE2) in gingival crevicular fluid (GCF) in a cohort of periodontal disease-resistant (PDR) adults with chronic gingivitis but with minimal evidence of bone loss, and to compare these data with GCF-PGE2 levels in patients with untreated chronic adult periodontal disease (CAPD). 20 PDR and 35 CAPD subjects with mean (+/-se) ages 52.4 (+/-2.9) and 43.7 (+/-1.2) years respectively, were recruited. GCF was sampled from 6 sites in each PDR subject and 4 sites in each CAPD subject. The GCF-PGE2 concentrations were determined by enzyme immunoassay (Assay Designs). Whole mouth medians of site-specific GCF-PGE2 concentrations were calculated for each subject. The means of the median GCF-PGE2 concentrations were: PDR 54.94+/-4.06 ng/ml; CAPD 41.57+/-2.91 ng/ml (p=0.009). We hypothesise that the higher concentrations of PGE2 in the PDR group may be associated with the proliferating pocket epithelia of the chronic gingivitis. In the CAPD cohort, there were no differences in GCF-PGE2 concentrations between subgroups of smokers (n=13), ex-smokers (n=11) and non smokers (n=11). In the PDR cohort, 19/20 subjects were non-smokers.