1.2% Rosuvastatin Versus 1.2% Atorvastatin Gel Local Drug Delivery and Redelivery in Treatment of Intrabony Defects in Chronic Periodontitis: A Randomized Placebo-Controlled Clinical Trial

Topical statins as antifungals: a review

Cutaneous fungal infections affect millions around the world. However, severe, multi-resistant fungal infections are increasingly being reported over the past years. As a result of the high rate of resistance which urged for drug repurposing, statins were studied and found to have multiple pleiotropic effects, especially when combined with other already-existing drugs. An example of this is the synergism found between several typical antifungals and statins, such as antifungals Imidazole and Triazole with a wide range of statins shown in this review. The main mechanisms in which they exert an antifungal effect are ergosterol inhibition, protein prenylation, mitochondrial disruption, and morphogenesis/mating inhibition. This article discusses multiple in vitro studies that have proven the antifungal effect of systemic statins against many fungal species, whether used alone or in combination with other typical antifungals. However, as a result of the high rate of drug-drug interactions and the well-known side effects of systemic statins, topical statins have become of increasing interest. Furthermore, patients with dyslipidemia treated with systemic statins who have a new topical fungal infection could benefit from the antifungal effect of their statin. However, it is still not indicated to initiate systemic statins in patients with topical mycotic infections if they do not have another indication for statin use, which raises the interest in using topical statins for fungal infections. This article also tackles the different formulations that have been studied to enhance topical statins' efficacy, as well as the effect of different topical statins on distinct dermatologic fungal diseases.

The Use of Statins as an Adjunctive Periodontal Disease Treatment: Systematic Review and Meta-Analysis

BACKGROUND

the purpose of this systematic review was to assess the clinical and radiographic effect of subgingival-administered statins as an adjunct periodontal treatment in patients with periodontitis.

METHODS

Electronic literature searches in Medline/PubMed and the Cochrane Library were conducted to identify all relevant articles. Eligibility was based on inclusion criteria which included Randomized Controlled Trials (RCTs) published after 2010, where the periodontal variables were assessed before and after periodontal treatment in combination with a statin administration. The risk of bias was assessed with the ROBINS-2 tool. The outcome variables were probing depth, clinical attachment level, bleeding on probing, and bone fill in systematically healthy patients, patients with type 2 diabetes, and smokers.

RESULTS

Out of 119 potentially eligible articles, 18 randomized controlled trials were included with a total of 1171 participants. The data retrieved from the meta-analysis showed the positive effect that statins have as an adjunctive periodontal disease treatment. When comparing the different types of statins, the PD reduction in the Simvastatin group was significantly higher than the Atorvastatin group at 6 months and at 9 months, while no differences between statins were found for the rest of the outcomes. Over 66% of the articles presented an overall risk of bias with some concerns, making this a limitation of this present RCT.

CONCLUSIONS

The adjunct administration of statins has proven to have a positive effect on the periodontium by improving both clinical and radiographic parameters by a considerable margin.

Association between antihyperlipidemic agents and the risk of chronic periodontitis in patients with hyperlipidemia: A population-based retrospective cohort study in Taiwan

BACKGROUND

The lipid-lowering and anti-inflammatory effects of statins and fibrates may ameliorate periodontitis. Patients with hyperlipidemia tend to have a worse periodontal status. This study assessed the association between the use of statins/fibrates and the incidence of chronic periodontitis in patients with hyperlipidemia in Taiwan.

METHODS

This retrospective cohort study enrolled patients newly diagnosed with hyperlipidemia between 2001 and 2012 from the 2000 Longitudinal Generation Tracking Database and followed them for 5 years. The study population was divided into four groups: statin monotherapy, fibrate monotherapy, combination therapy (both statins and fibrates), and control (neither statins nor fibrates). Each patient in the treatment group was matched at a ratio of 1:1 with a control. Chronic periodontitis risk was compared in the three study arms by using a Cox proportional hazard model.

RESULTS

Chronic periodontitis risk was reduced by 25.7% in the combination therapy group compared with the control group (adjusted hazard ratio [aHR], 0.743; 95% confidence interval (CI), 0.678-0.815). Low dose (<360 cumulative defined daily dose [cDDD]) and shorter duration (<2 years) of statin monotherapy seem to be associated with an increased risk of chronic periodontitis; high dose (≥720 cDDD/≥1080 cDDD) and longer duration (≥3 years) of statin/fibrate monotherapy may be correlated with a lower risk of periodontitis. Hydrophobic statin users had a lower chronic periodontitis risk than hydrophilic statin users.

CONCLUSION

Chronic periodontitis risk was lower in patients with hyperlipidemia on combination treatment with statins and fibrates, and the risk decreased when patients used statins or fibrates for >3 years.

From Basic Science to Clinical Practice: A Review of Current Periodontal/Mucogingival Regenerative Biomaterials

Periodontitis is a dysbiosis-driven inflammatory disease affecting the tooth-supporting tissues, characterized by their progressive resorption, which can ultimately lead to tooth loss. A step-wise therapeutic approach is employed for periodontitis. After an initial behavioral and non-surgical phase, intra-bony or furcation defects may be amenable to regenerative procedures. This review discusses the regenerative technologies employed for periodontal regeneration, highlighting the current limitations and future research areas. The search, performed on the MEDLINE database, has identified the available biomaterials, including biologicals (autologous platelet concentrates, hydrogels), bone grafts (pure or putty), and membranes. Biologicals and bone grafts have been critically analyzed in terms of composition, mechanism of action, and clinical applications. Although a certain degree of periodontal regeneration is predictable in intra-bony and class II furcation defects, complete defect closure is hardly achieved. Moreover, treating class III furcation defects remains challenging. The key properties required for functional regeneration are discussed, and none of the commercially available biomaterials possess all the ideal characteristics. Therefore, research is needed to promote the advancement of more effective and targeted regenerative therapies for periodontitis. Lastly, improving the design and reporting of clinical studies is suggested by strictly adhering to the Consolidated Standards of Reporting Trials (CONSORT) 2010 statement.

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

Objective

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

Methods

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

Results

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

Conclusion

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

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

BACKGROUND

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

HIGHLIGHT

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

CONCLUSION

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

Sub-gingival delivery of simvastatin and rosuvastatin for treatment of chronic periodontitis with diabetes mellitus: A randomized controlled clinical-radiographic pilot study

Background

Statins are lipid-lowering medications that work by blocking rate-limiting enzyme in cholesterol formation. In patients with Chronic periodontitis (CP) and Diabetes mellitus (DM), subgingival delivery of simvastatin (SMV) and rosuvastatin (RSV) have demonstrated to have bone-stimulatory and anti-inflammatory properties. The current study intended to assess and compare the efficacy of sub-gingivally delivered SMV gel and RSV gel as an adjunctive medication to scaling and root planing (SRP) in the management of intrabony defects in CP patients with type 2 DM.

Methods

30 patients with CP and type 2 DM were classified into three treatment groups - SRP + placebo, SRP +1.2% SMV and SRP +1.2% RSV. Clinical parameters: site-specific plaque index, modified sulcus bleeding index (mSBI), pocket probing depth (PPD), and relative attachment level (RAL) were documented at baseline, 3 and 6 months and radiographic parameter: intrabony defect depth (IBD) at baseline and 6 months post-treatment.

Results

- LDD of 1.2% SMV and 1.2% RSV demonstrated greater clinical and radiographic improvement than placebo, the improvement being statistically significant for PI, mSBI, and PPD for 1.2% SMV and statistically significant for all clinical and radiological parameters for the 1.2% RSV. 1.2% RSV demonstrated greater IBD fill and RAL gain than 1.2% SMV.

Conclusion

- Localized sub-gingival delivery of statins was beneficial in the treatment intrabony defects in patients with CP and well-controlled type 2 DM. IBD fill and RAL gain were higher with 1.2% RSV than with 1.2% SMV.

New Frontiers on Adjuvants Drug Strategies and Treatments in Periodontitis

Causes of the progression of periodontitis such as an imbalance between the immune response by the host by the release of inflammatory mediators in the response of the oral pathogenic dysbiotic biofilm have been identified. New insights on specific cell signaling pathways that appear during periodontitis have attracted the attention of researchers in the study of new personalised approaches for the treatment of periodontitis. The gold standard of non-surgical therapy of periodontitis involves the removal of supra and subgingival biofilm through professional scaling and root planing (SRP) and oral hygiene instructions. In order to improve periodontal clinical outcomes and overcome the limitations of traditional SRP, additional adjuvants have been developed in recent decades, including local or systemic antibiotics, antiseptics, probiotics, anti-inflammatory and anti-resorptive drugs and host modulation therapies. This review is aimed to update the current and recent evolution of therapies of management of periodontitis based on the adjunctive and target therapies. Moreover, we discuss the advances in host modulation of periodontitis and the impact of targeting epigenetic mechanisms approaches for a personalised therapeutic success in the management of periodontitis. In conclusion, the future goal in periodontology will be to combine and personalise the periodontal treatments to the colonising microbial profile and to the specific response of the individual patient.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

KNOWLEDGE TRANSFER STATEMENT

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

Unusual Findings in Trials Evaluating Adjuncts to Scaling and Root Planing: Reporting Quality (Part 2)

INTRODUCTION

On the topic of adjuncts to scaling and root planing (SRP), numerous randomized clinical trials (RCTs) were published by a single group of authors and frequently reported unusually large effect sizes. A meta-analysis in part 1 of this project failed to explain the causes for these unusual findings. We assessed the reporting quality and trial registration discrepancies to examine the possibility of replicating the work of this research group as well as the overall rigor of the research methodology.

METHODS

This study was preregistered at the Open Science Framework (https://osf.io/4meyd/). The Scopus platform was utilized for the RCT search on SRP adjuncts in intrabony defects in patients with periodontitis as compared with SRP alone. The search analysis was limited from 2010 to 2017, and RCTs on SRP adjuncts published by a single research group were selected for screening and inclusion. RCT registration records were assessed for consistency.

RESULTS

Out of 92 studies that were retrieved from Scopus and PubMed, 32 were included for quality assessment per the CONSORT guidelines (Consolidated Standards of Reporting Trials). Results showed that all RCTs were characterized by a low reporting quality. The majority of CONSORT items scored <50%, including critical items (randomization, registration, and blinding). When registration records were compared with published RCTs, several discrepancies were found. The per-protocol follow-up duration was compared against the study's initiation and termination dates. Only 38% of the RCTs presented a follow-up period within the initiation and termination dates. The remaining RCTs showed inconsistent follow-up in comparison with the initiation and termination dates.

CONCLUSION

RCTs by this group were characterized by poor adherence to reporting quality guidelines. Crucial RCT elements, such as randomization, blinding, and primary outcomes, were not reported properly. RCT registration records revealed systematic inconsistencies when compared with RCT publication. Therefore, the unusually large effects reported by this group should be viewed with extreme caution.

KNOWLEDGE TRANSFER STATEMENT

The included randomized clinical trials were characterized by poor adherence to reporting quality guidelines, missing information about important trial items, and discrepancies between the reports and trial registrations. This quality assessment should guide clinical research and show clinicians that they should be cautious when applying evidence in their clinical practice.

New tendencies in non-surgical periodontal therapy

The aim of this review was to update the evidence of new approaches to non-surgical therapy (NSPT) in the treatment of periodontitis. Preclinical and clinical studies addressing the benefits of adjunctive antimicrobial photodynamic therapy, probiotics, prebiotics/synbiotics, statins, pro-resolving mediators, omega-6 and -3, ozone, and epigenetic therapy were scrutinized and discussed. Currently, the outcomes of these nine new approaches, when compared with subgingival debridement alone, did not demonstrate a significant added clinical benefit. However, some of these new alternative interventions may have the potential to improve the outcomes of NSPT alone. Future evidence based on randomized controlled clinical trials would help clinicians and patients in the selection of different adjunctive therapies.

PRP and PRF-Subgroups and Divisions When Used in Dentistry

Blood derivates, such as platelet-rich plasma (PRP) and platelet-rich fibrin (PRF), are autogenous sources of many growth factors that are involved in the healing and regeneration of tissues, and for this reason, are used in dentistry treatments. This fact also contributes to the growing interest in these biomaterials in regenerative personalized medicine. The multitude of platelet-rich forms creates many possibilities for their use. This semi-systematic review describes and compares the methods of obtaining properties and potential uses of these materials in personalized treatments.

STATINSWITH POTENTIAL TO CONTROL PERIODONTITIS: FROM BIOLOGICAL MECHANISMS TO CLINICAL STUDIES

BACKGROUND

Statins are widely used for the treatment of hyperlipidemia. However, these drugs have pleiotropic effects that can be promising for the prevention and treatment of oral diseases, such as periodontitis.

HIGHLIGHT

This review aimed to identify preclinical, observational, and clinical studies that evaluate the effects and biological mechanisms of statins on oral cells and tissues and those using these drugs to treat periodontitis. A LITERATURE SURVEY HAS BEEN CONDUCTED IN PUBMED USING COMBINATIONS OF THE UNITERMS: "statins," "dentistry," "periodontal disease," and "periodontal treatment." In vitro findings showed positive statin results in cell lines related to alveolar bone metabolism by altering the signaling pathway Osteoprotegerin/Receptor Activator of Nuclear Factor Kappa B/Receptor Activator of Nuclear Factor Kappa B Ligand (OPG/RANK/RANKL), stimulating the production of alkaline phosphatase and osteocalcin, and reducing the production of matrix metalloproteinases (MMPs). Animal studies have shown a reduction in alveolar bone loss and osteoclastic activity, in addition to a reduction in inflammatory markers, such as IL-1, IL-6, and TNF-α, when statins were used prophylactically. Clinical trials showed a positive impact on clinical parameters, leading to a higher reduction in probing depth and gain in clinical attachment when a local statin was adjunctively associated with mechanical therapy.

CONCLUSION

Statins were shown to be promising for regenerating and stimulating bone activity, with great potential for treating chronic periodontitis. However, further studies are required to confirm its effectiveness.

Clinical efficacy of simvastatin gel combined with polypropylene membrane on the healing of extraction sockets: A triple-blind, randomized clinical trial

OBJECTIVES

This study aimed to evaluate dimensional changes, level of soft tissue healing, and pain/discomfort perception in post-extraction sockets filling with 1.2% simvastatin (SIM) gel covered with polypropylene membranes (PPPM).

MATERIAL AND METHODS

Twenty-six post-extraction sockets of posterior teeth were randomly allocated in two groups: (a) socket filling with 1.2% SIM gel and covered with PPPM (n = 13) and (b) socket filling with placebo gel and covered with PPPM (n = 13). Cone-beam computed tomography (CBCT) images before and 90 days after the extraction enabled alveolar bone dimensional changes calculation using horizontal and vertical measurements. The measurements occurred at three different levels for thickness located 1, 3, and 5 mm from the top of the bone crest. The vertical (depth) measure was assessed from the most apical portion of the socket to the bone crest's most coronal portion. Seven days after the extractions, the level of soft tissue healing and pain perception were also analyzed.

RESULTS

After 90 days of extractions, the dimensional changes in thickness in the test group were significantly smaller in sections A (p = .044), B (p = .036) and C (p = .048) when compared to the control group. The test group showed a significantly lower height-dimensional change than the control group (p < .0001). Soft tissue healing index (p = .63), perception of pain (p = .23), and number of analgesics consumed (p = .25) were similar between groups.

CONCLUSIONS

Simvastatin at 1.2% compared with placebo effectively reduced the dimensional changes in post-extraction sockets covered with PPPM. There was no significant difference in the level of soft tissue healing and postoperative pain between the test and control groups.

The adjunctive use of host modulators in non-surgical periodontal therapy. A systematic review of randomized, placebo-controlled clinical studies

BACKGROUND

Considering the role of the inflammatory host response in the pathogenesis of periodontitis, different host modulators have been proposed to enhance the outcomes of non-surgical periodontal therapy (NSPT), but their efficacy has not been fully clarified.

OBJECTIVES

This systematic review investigated the efficacy of host modulators combined with NSPT in reducing probing pocket depth (PPD) in periodontitis patients.

MATERIALS AND METHODS

Placebo-controlled RCTs with ≥6 months follow-up were searched. Meta-analysis was conducted when ≥5 studies using the same host modulator were identified.

RESULTS

Fifty eight studies met the inclusion criteria. After 6 months, local administration of 1.2% statin gels as adjuncts to NSPT significantly improved PPD reduction (1.83 mm) in infrabony defects and systemic administration of sub-antimicrobial dose doxycycline (SDD) in addition to NSPT improved PPD reduction of deep pockets. Administration of probiotics conferred limited clinical benefits. Local bisphosphonate and metformin gels showed potential for clinical use in infrabony defects, which needs to be confirmed.

CONCLUSIONS

Local delivery of statins in infrabony defects and systemic SDD for deep pockets may confer additional clinical benefits to NSPT. Their long-term effectiveness and safety need to be confirmed in independent multi-centred studies. Further studies are needed to confirm the benefit of other host modulators.

Host Modulation and Treatment of Periodontal Disease

Periodontitis is the sixth-most prevalent disease in the world and the first cause for tooth loss in adults. With focus shifted to the inflammatory/immune response in the pathogenesis of periodontitis, there is a critical need to evaluate host modulatory agents. Synthetic and biological disease-modifying antirheumatic drugs are a cornerstone for the treatment of inflammatory diseases. Recent prospective cohort studies showed that synthetic disease-modifying antirheumatic drugs improved periodontal clinical parameters following nonsurgical periodontal treatment in patients with rheumatoid arthritis. Treatment with recombinant humanized monoclonal antibodies against CD20 (rituximab) and IL-6 receptor (tocilizumab), the latter also in clinical trials for the treatment of COVID-19 pneumonia, resulted in decreased periodontal inflammation and improved periodontal status. Studies on the effect of TNF-α inhibitors in patients with periodontitis yielded inconsistent results. Recent data suggest that probiotics provide anti-inflammatory clinical benefit, as do nutritional supplements, such as n-3 fatty acids, when combined with periodontal therapy. Probiotics reduce the production of proinflammatory cytokines/chemokines by suppressing NF-κB pathways and promote the accumulation of T regulatory cells. Statins, like aspirin, have been shown to exhibit anti-inflammatory and bone-preserving actions by upregulating production of Specialized Proresolving Mediators (SPMs). Currently, there is insufficient scientific support for the topical delivery of statins or bisphosphonates as adjuncts to periodontal therapy. Here, we present a critical review of the most recent host modulatory agents applied in humans and the key immune pathways that they target. Emerging evidence from novel drug candidates, including SPMs and complement inhibitors as previously studied in animal models and currently in human clinical trials, suggests future availability of adjunctive therapeutic strategies for the management of periodontitis.

Regulation of Osteoclast Differentiation and Activity by Lipid Metabolism

Bone is a dynamic tissue and is constantly being remodeled by bone cells. Metabolic reprogramming plays a critical role in the activation of these bone cells and skeletal metabolism, which fulfills the energy demand for bone remodeling. Among various metabolic pathways, the importance of lipid metabolism in bone cells has long been appreciated. More recent studies also establish the link between bone loss and lipid-altering conditions—such as atherosclerotic vascular disease, hyperlipidemia, and obesity—and uncover the detrimental effect of fat accumulation on skeletal homeostasis and increased risk of fracture. Targeting lipid metabolism with statin, a lipid-lowering drug, has been shown to improve bone density and quality in metabolic bone diseases. However, the molecular mechanisms of lipid-mediated regulation in osteoclasts are not completely understood. Thus, a better understanding of lipid metabolism in osteoclasts can be used to harness bone cell activity to treat pathological bone disorders. This review summarizes the recent developments of the contribution of lipid metabolism to the function and phenotype of osteoclasts.

Antifungal efficacy of atorvastatin-containing emulgel in the treatment of oral and vulvovaginal candidiasis

Drug repositioning has been an important ally in the search for new antifungal drugs. Statins are drugs that act to prevent sterol synthesis in both humans and fungi and for this reason they are promissory candidates to be repositioned to treat mycoses. In this study we evaluated the antifungal activity of atorvastatin by in vitro tests to determine the minimum inhibitory concentration against azole resistant Candida albicans and its mechanisms of action. Moreover, the efficacy of both atorvastatin-loaded oral and vaginal emulgels (0.75%, 1.5% and 3% w/w) was evaluated by means of in vivo experimental models of oral and vulvovaginal candidiasis, respectively. The results showed that atorvastatin minimal inhibitory concentration against C. albicans was 31.25 μg/ml. In oral candidiasis experiments, the group treated with oral emulgel containing 3.0% atorvastatin showcased total reduction in fungal load after nine days of treatment. Intravaginal delivery atorvastatin emulgel showed considerable effectiveness at the concentration of 3% (65% of fungal burden reduction) after nine days of treatment. From these findings, it is possible to assert that atorvastatin may be promising for drug repositioning towards the treatment of these opportunistic mycoses.

Repurposing of drugs approved for cardiovascular diseases: Opportunity or mirage?

Drug repurposing is a promising way in drug discovery to identify new therapeutic uses -different from the original medical indication- for existing drugs. It has many advantages over traditional approaches to de novo drug discovery, since it can significantly reduce healthcare costs and development timeline. In this review, we discuss the possible repurposing of drugs approved for cardiovascular diseases, such as β-blockers, angiotensin converting enzyme inhibitors (ACE-Is), angiotensin II receptor blockers (ARBs), statins, aspirin, cardiac glycosides and low-molecular-weight heparins (LMWHs). Indeed, numerous experimental and epidemiological studies have reported promising anti-cancer activities for these drugs. It is worth mentioning, however, that the results of these studies are often controversial and very few data were obtained by controlled prospective clinical trials. Therefore, no final conclusion has yet been reached in this area and no final recommendations can be made. Moreover, β-blockers, ARBs and statins showed promising results in randomised controlled trials (RCTs) where pathological conditions other than cancer were considered. The results obtained have led or may lead to new indications for these drugs. For each drug or class of drugs, the potential molecular mechanisms of action justifying repurposing, results obtained in vitro and in animal models and data from epidemiological and randomized studies are described.

Efficacy of locally-delivered statins adjunct to non-surgical periodontal therapy for chronic periodontitis: a Bayesian network analysis

BACKGROUND

Studies indicate locally-delivered statins offer additional benefits to scaling and root planning (SRP), however, it is still hard to say which type of statins is better. This network meta-analysis aimed to assess the effect of locally-delivered statins and rank the most efficacious statin for treating chronic periodontitis (CP) in combination with SRP.

METHODS

We screened four literature databases (Pubmed, Embase, Cochrane Library, and Web of Science) for randomized controlled clinical trials (RCTs) published up to June 2018 that compared different statins in the treatment of chronic periodontitis. The outcomes analyzed were changes in intrabony defect depth (IBD), pocket depth (PD), and clinical attachment level (CAL). We carried out Bayesian network meta-analysis of CP without systemic diseases. Traditional and Bayesian network meta-analyses were conducted using random-effects models.

RESULTS

Greater filling of IBD, reduction in PD, and gain in CAL were observed for SRP treated in combination with statins when compared to SRP alone for treating CP without systemic diseases. Specifically, SRP+ Atorvastatin (ATV) (mean difference [MD]: 1.5 mm, 1.4 mm, 1.8 mm, respectively), SRP + Rosuvastatin (RSV) (MD: 1.8 mm, 2.0 mm, 2.1 mm, respectively), and SRP + Simvastatin (SMV) (MD: 1.1 mm, 2.2 mm, 2.1 mm, respectively) were identified. However, no difference was found among the statins tested. In CP patients with type 2 diabetic (T2DM) or in smokers, additional benefits were observed from locally delivered statins.

CONCLUSION

Local statin use adjunctive to SRP confers additional benefits in treating CP by SRP, even in T2DM and smokers. RSV may be the best one to fill in IBD. However, considering the limitations of this study, clinicians must use cautious when applying the results and further studies are required to explore the efficacy of statins in CP with or without the risk factors (T2DM comorbidity or smoking history).

Efficacy of Locally Administered 1.2% Rosuvastatin Gel in Patients with Periodontitis: A Randomized Placebo Controlled Clinical Trial

Objective Periodontitis initiation and progression are a result of host immune inflammatory response to oral pathogens. Several pharmacological agents are being delivered locally, to improve periodontal health. Hence, the present randomized placebo controlled clinical trial is designed to check the clinical and antimicrobial efficacy of locally delivered 1.2% rosuvastatin (RSV) in intrabony defects (IBD) in periodontitis patients.

Materials and Methods One-hundred patients were randomly allotted into two treatment groups: group A received 1. 2% RSV gel, scaling and root debridement and group B received placebo gel, scaling and root debridement. Clinical parameters, including modified sulcus bleeding index (mSBI), probing depth (PD), clinical attachment level (CAL), and plaque index (PI), were recorded at baseline before phase 1 and after 6 months. Radiographic assessment of IBD was done by cone beam computed tomography at baseline and after 6 months. Anaerobic colony count was done at baseline and after 180 days.

Results On intragroup comparison, there is a significant improvement in periodontal parameters in both the groups. On intergroup comparison, there is significant gain in CAL in group A than group B ( p = 0.04). There is significant decrease in PD in group A, compared to group B. There is significant bone fill in group A ( p = 0.034), compared to group B. With respect to mSBI, PI, and anaerobic colony count, there is no significant difference between the two groups after 6 months. No adverse effect was noticed in any subjects.

Conclusion The author concludes that 1.2% RSV gel when delivered locally into IBD improved periodontal clinical parameters such as PD and CAL and showed significant bone fill.

Periodontal complications of prescription and recreational drugs

Drug use for both therapeutic and recreational purposes is very widespread in most societies. The range of drugs used, the variations in response to these drugs and other health and behavioral confounders mean that drug use may be an important contributor to individualized periodontal diagnoses. In this narrative review, we review the main reported effects of drugs on the periodontal tissues and periodontal disease processes. Although some of the more common adverse drug reactions on periodontal tissues are well described, in many other cases the evidence for these drug effects is quite limited and based on small case series or isolated reports. Prescription drugs are responsible for a range of effects, including drug-induced gingival overgrowth and increased gingival bleeding, and influence periodontal inflammation and periodontal breakdown. The effects of recreational drugs on the periodontal tissues is less well researched, perhaps for the obvious reason that assembling large cohorts of recreational drug users presents particular challenges. Use of nearly all of these substances is associated with poorer periodontal and dental health, although there is almost certainly a large degree of behavioral confounding in these findings. Overall, further studies of adverse drug reactions on the periodontal tissues are required as this continues to be an important and increasing factor in periodontal health determination.

Contribution of Statins towards Periodontal Treatment: A Review

The pleiotropic effects of statins have been evaluated to assess their potential benefit in the treatment of various inflammatory and immune-mediated diseases including periodontitis. Herein, the adjunctive use of statins in periodontal therapy in vitro, in vivo, and in clinical trials was reviewed. Statins act through several pathways to modulate inflammation, immune response, bone metabolism, and bacterial clearance. They control periodontal inflammation through inhibition of proinflammatory cytokines and promotion of anti-inflammatory and/or proresolution molecule release, mainly, through the ERK, MAPK, PI3-Akt, and NF-κB pathways. Moreover, they are able to modulate the host response activated by bacterial challenge, to prevent inflammation-mediated bone resorption and to promote bone formation. Furthermore, they reduce bacterial growth, disrupt bacterial membrane stability, and increase bacterial clearance, thus averting the exacerbation of infection. Local statin delivery as adjunct to both nonsurgical and surgical periodontal therapies results in better periodontal treatment outcomes compared to systemic delivery. Moreover, combination of statin therapy with other regenerative agents improves periodontal healing response. Therefore, statins could be proposed as a potential adjuvant to periodontal therapy. However, optimization of the combination of their dose, type, and carrier could be instrumental in achieving the best treatment response.

The effect of local and systemic statin use as an adjunct to non-surgical and surgical periodontal therapy-A systematic review and meta-analysis

OBJECTIVES

To evaluate the effect of local and/or systemic statin use as an adjunct to non-surgical and/or surgical periodontal therapy.

DATA

Literature search according to PRISMA guidelines with the following eligibility criteria: (a) English or German language; (b) interventional studies; (c) statins as monotherapy or as an adjunct to non-surgical and/or surgical treatment of periodontitis; (d) clinical and/or radiographic treatment effect size of statin intake reported.

SOURCES

Medline (PubMed), Embase (Ovid), CENTRAL (Ovid).

STUDY SELECTION

Thirteen clinical studies regarding local application and 2 with systemic administration of statins as an adjunct to non-surgical treatment (SRP) and 4 studies regarding intrasurgical statin application with a maximum follow-up of 9 months could be included; simvastatin, atorvastatin, and rosuvastatin were used. Local but not systemic statin application as an adjunct to SRP yielded significantly larger probing pocket depth (PD), radiographic defect depth (RDD), and bleeding index reduction, and larger clinical attachment level gain, and less residual PD and RDD (p≤0.016); rosuvastatin appeared as the most efficacious. Three of 4 studies reported a significant positive effect of intrasurgical statin application. No adverse events were reported after statin use. The vast majority of the included studies were from the same research group.

CONCLUSIONS

Significant additional clinical and radiographic improvements are obtained after local, but not systemic, statin use as an adjunct to SRP in deep pockets associated with intrabony defects and seemingly with furcation defects; intrasurgical statin application seems similarly beneficial. Confirmation of these results, and especially of the effect size, from other research groups is warranted.

The effect of statins on periodontal treatment-a systematic review with meta-analyses and meta-regression

OBJECTIVE

This study aimed to systematically review clinical trials about the effect of statins as adjunct to mechanical periodontal therapy, on probing pocket depth, clinical attachment level, and intrabony defects, in comparison to mechanical periodontal therapy alone or in association with placebo.

MATERIAL AND METHODS

Three databases were searched for controlled clinical trials that used any locally delivered or systemically statin as a sole adjunctive therapy to mechanical periodontal treatment. Weighted mean differences between baseline and 6 months after periodontal treatment for clinical attachment level (CAL), probing pocket depth (PPD), and intrabony defect (IBD) were calculated. A high heterogeneity was detected. Therefore, a meta-regression adjusted for type of statin and year of publication was performed.

RESULTS

Fifteen studies were included in the systematic review, and ten studies were included in the meta-analysis. In the meta-regression, the adjunct use of simvastatin, rosuvastatin, and atorvastatin additionally reduced PPD in comparison to mechanical periodontal therapy and a placebo gel (2.90 ± 0.35, 3.90 ± 0.77, 3.06 ± 0.71 mm, respectively; p < 0.05). Regarding the resolution of IBD, simvastatin and rosuvastatin significantly improved in comparison to control group (0.89 ± 0.35 and 1.93 ± 0.77 mm, respectively; p < 0.05). No statistically significant difference was found between the statins for both PPD and IBD (p < 0.05). Regarding CAL gain, simvastatin provided a statistically significant improvement as compared to the control group (2.02 ± 0.79 mm; p = 0.043).

CONCLUSIONS

The use of statins, used as sole adjuncts to mechanical periodontal treatment, improved the periodontal parameters. In the quantitative analyses, simvastatin was the only drug that showed additional benefits in all evaluated parameters.

CLINICAL RELEVANCE

Statins promote significantly clinical periodontal improvements when administered in association with non-surgical scaling and root planning (SRP), when compared to SRP alone or in association with a placebo.

Efficacy of statin delivery as an adjunct to scaling and root planing in the treatment of chronic periodontitis: A meta-analysis

The action of statins in stimulating bone formation and having other pleiotropic effects, such as anti-inflammatory and immunomodulatory effects, has justified their use as an adjunct to scaling and root planing (SRP) in the treatment of chronic periodontitis (CP). The aim of the present study was to evaluate the efficacy of statin delivery as an adjunct to SRP in the treatment of CP. Electronic searches were conducted using the following databases: MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, and Cochrane Oral Health Group Trials Register, up until July 2017. The primary outcome was probing depth (PD), while the secondary outcomes were changes in clinical attachment level (CAL) and bone defect (BD) fill. Eleven studies were included, and all showed significant PD reduction, CAL gain, and BD fill with adjunctive statin delivery compared to SRP alone. The meta-analysis showed significant improvement in periodontal parameters for atorvastatin (PD: weighted mean difference [WMD] = -1.84, -2.56 to -1.12, P < .001; CAL: WMD = -2.31, -3.58 to -1.03, P < .001; BD fill: WMD = 2.66, -3.92 to -1.39, P < .001), simvastatin (PD: WMD = -1.91, -2.27 to -1.55, P < .001; CAL: WMD = -1.91, -2.27 to -1.55, P = .001; BD: WMD = -1.52, -2.20 to -0.85, P < .001), and rosuvastatin (PD: WMD = -0.94, -1.32 to -0.55, P < .001; CAL: WMD = -1.00, -1.41 to -0.60, P < .001; BD fill: WMD = -1.30, -1.80 to -0.79, P < .001). Adjunctive statin delivery appears to be effective in reducing PD, CAL gain, and BD fill in CP, and therefore, these drugs could be a promising therapeutic option for periodontal regeneration in future.

Does the adjunctive use of statins provide additional benefits to nonsurgical periodontal treatment? A systematic review and meta-analysis

Adjunctive therapeutic agents may be used to improve the response to nonsurgical periodontal therapy. Local delivery of statins (simvastatin, artovastatin and rosuvastatin) is a promising adjunct to scaling and root planing (SRP). Thus, the aim of this review is to evaluate if adjunctive local delivery of statins is more effective than SRP alone. Randomized clinical trials that presented a test group evaluating local delivery of statins as adjuncts in healthy, diabetic and smoking patients were included. Medline and the Cochrane library database were searched up to November 2016. Random effects meta-analyses were conducted for pocket depth change and clinical attachment gain. One hundred and twenty-five studies potentially related to the aim of this review were screened, but only 10 were included. The majority of the trials reported additional clinical benefits in the groups that were treated with adjunctive local delivery of statins. Pooled calculations showed that local delivery of statins resulted in additional reduction of pocket depth and clinical attachment gain in healthy people, smokers and diabetic patients. Local statins may offer additional clinical benefits to SRP, even in smokers and diabetics.

The Effect of Locally Delivered Statins on Treating Periodontal Intrabony Defects: A Systematic Review and Meta-Analysis

BACKGROUND

Use of statins on adult patients with chronic periodontitis shows a positive effect on their periodontal status. However, effect of locally delivered statins on periodontal treatment has not yet been systematically analyzed. Hence, the present systematic review and meta-analysis aims to evaluate efficacy of statins on treating localized periodontal intrabony defects (IBDs).

METHODS

An electronic search of three databases (PubMed, Embase, and Cumulative Index to Nursing and Allied Health Literature) between January 1, 1965 and March 1, 2016, and a hand search of peer-reviewed journals for relevant articles were performed. Controlled randomized clinical trials (RCTs) and prospective studies with data on comparison between adjunctive locally delivered statin use to mechanical scaling and root planing (SRP) and placebo in each group, with minimum 10 participants and follow-up period of at least 6 months, were included.

RESULTS

Ten studies, eight RCTs and two prospective studies, were included. Each study included 15 to 105 patients between 25 and 55 years of age. Statistical results were recorded; weighted mean difference (WMD) and confidence interval (CI) were calculated; and meta-analyses were performed for defect fill, probing depth (PD) reduction, and clinical attachment level (CAL) gain in both statin and placebo/no treatment groups. Overall analysis of defect fill presented WMD of 1.37 mm (95% CI = 0.96 to 1.77; P <0.0001), PD reduction presented WMD of 1.76 mm (95% CI = 1.04 to 2.47; P <0.0001), and CAL gain presented WMD of 1.58 mm (95% CI = 0.89 to 2.28; P <0.0001). However, comparison presented considerable heterogeneity among studies.

CONCLUSIONS

This systematic review and meta-analysis find that adjunctive use of locally delivered statins to mechanical SRP is beneficial to increasing bone fill percentage. Improved inflammatory and bleeding control as well as PD reduction and CAL gain are possible advantages to using these drugs in treating patients with periodontal IBDs.