The long-term effect of systemic tetracycline used as an adjunct to non-surgical treatment of advanced periodontitis

Decision-making on systemic antibiotics in the management of periodontitis: A retrospective comparison of two concepts

AIM

To retrospectively compare two approaches for the adjunctive use of systemic antibiotics in non-surgical periodontal therapy: one based on the detection of Aggregatibacter actinomycetemcomitans (Aa) and the other on age and severity of periodontitis (Age & PPD). We also assessed the additional benefit of antibiotics in reducing the need for further surgical therapy in each group.

MATERIALS AND METHODS

Patients of the Department of Periodontology, Goethe University Frankfurt, Germany, were screened for microbiological testing between 2008 and 2018. Patients were categorized by their microbiological result (Aa+/-) and demographic/clinical data (Age & PPD+/-). Agreement on antibiotic indication was tested. The clinical evaluation focussed on teeth with probing pocket depths (PPDs) ≥ 6 mm.

RESULTS

Analysis of 425 patients revealed 30% categorized as Age & PPD+ and 34% as Aa+. Sixty-three percent had consistent antibiotic recommendations (phi coefficient 0.14, p = .004). Patients in the Age & PPD+ group receiving antibiotics showed the most substantial reduction in the number of teeth with PPD ≥ 6 mm after non-surgical periodontal therapy.

CONCLUSIONS

Both strategies resulted in a significant clinical improvement compared with those without antibiotic treatment and restricted antibiotic use similarly, but targeted different patient groups. Younger individuals with severe periodontitis benefited most from antibiotics, reducing the need for additional surgeries. The study was registered in an international trial register (German Clinical Trial Register number DRKS00028768, registration date 27 April 2022, https://drks.de/search/en/trial/DRKS00028768).

Clinical evaluation of chitosan/polycaprolactone nanofibrous scaffolds releasing tetracycline hydrochloride in periodontal pockets of patients with chronic periodontitis

Background

The role of bacteria in the initiation and progression of periodontitis has led to a great interest in using antibiotics to suppress pathogenic microbiota. Considering the drawbacks of systemic antibiotics' application, local delivery systems directly in the periodontal pocket can be helpful. Therefore, the effect of an efficient tetracycline-loaded delivery system was investigated on the clinical parameters of periodontitis.

Methods

In this clinical trial with a split-mouth design, 10 patients with periodontitis with pocket depths≥5 mm were included. After scaling and root planing (SRP) for all the patients, one side of the mouth was randomly considered as the control group, and on the other side, chitosan/polycaprolactone (PCL) nanofibrous films containing tetracycline (5%) were placed in pockets of 5 mm and deeper. Clinical measurements of pocket probing depth (PPD), clinical attachment loss (CAL), and bleeding on probing (BOP) indices were made at the beginning and after 8 weeks of intervention. PPD, CAL, and BOP parameters were compared between the control and test groups before and after the intervention with paired t tests using SPSS 24. The significance level of the tests was considered at P<0.05.

Results

The mean PPD, CAL, and BOP in both the control (SRP) and test (LDDs) groups decreased after 8 weeks. A significant difference was detected in reducing PPD, BOP, and CAL after 8 weeks in 5-mm pockets, and the mean values were higher in the test group than in the control (P<0.05).

Conclusion

The local drug delivery system using chitosan/PCL nanofibrous films containing tetracycline can effectively control periodontal diseases by reducing pocket depth and inflammation and improving CAL without offering side effects, although further evaluations are needed.

Tooth preservation vs. extraction and implant placement in periodontally compromised patients: A systematic review and analysis of studies

PURPOSE

The aim of this systematic review was to identify studies with a minimum of 5-years follow-up, reporting on the management of periodontally compromised teeth with either extraction and subsequent implant placement or teeth preservation with conventional periodontal treatment and application of regenerative procedures. The outcomes of these two approaches, based on clinical and radiographic data and the incidence of tooth- and implant-loss, were also investigated.

MATERIAL AND METHODS

A systematic search for studies reporting on clinical and radiographic outcomes of periodontal treatment or replacement of periodontally compromised teeth with implants was conducted in 3 electronic databases, followed by a hand-search in 8 journals. Only randomized controlled trials (RCTs), cohort studies, and case series with prospective design were included.

RESULTS

The initial search resulted in 1080 papers. After the first two screenings, 24 publications were selected for inclusion in this systematic review. The treatment protocols for the teeth preservation group contained nonsurgical and/or surgical periodontal treatment with or without regeneration procedures. The implant studies included extraction of periodontally involved teeth and implant placement with or without bone and soft tissue augmentation, followed by restoration with fixed dental prostheses (FDPs). Survival rates ranged between 81.8% and 100% in the tooth retention group, and between 94.8% and 100% in the implant group. In the extraction group, no complications were reported for 76.09% of the implants. Similarly, no complications were reported for 86.83% of the tooth retention group. The lack of standardized comparable studies prohibited conduction of a metaanalysis.

CONCLUSION

Both treatment approaches, treatment of periodontally compromised teeth, or tooth extraction followed by implant placement, present high survival rates. The application of bone regeneration techniques improves the long-term prognosis of periodontally involved teeth. Hence, treatment of periodontally involved teeth with subsequent application of a rigorous maintenance protocol can be a viable alternative for a number of years, before proceeding to extraction and replacement with dental implants. More well-designed randomized controlled trials are needed in order to draw definite conclusions on the subject.

A Systematic Review and Meta-Analysis of Systemic Antibiotic Therapy in the Treatment of Peri-Implantitis

Research has been conducted into the advantages of the systemic administration of antibiotics. The aim of this systematic review and meta-analysis was to assess the efficacy of systemic antibiotic administration in the treatment of peri-implantitis in terms of bleeding on probing (BoP) and probing pocket depth (PPD). Literature searches were performed across PubMed, EMBASE, and Cochrane Central Register of Controlled Trials (CENTRAL) to identify randomized controlled trials and observational clinical studies. After peri-implantitis treatment, PPD was reduced by 0.1 mm (p = 0.58; IC 95% [-0.24, 0.47]), indicating a non-significant effect of antibiotic administration on PPD. The BoP odds ratio value was 1.15 (p = 0.5; IC 95% [0.75, 1.75]), indicating that the likelihood of bleeding is almost similar between the test and control groups. Secondary outcomes were found, such as reduced clinical attachment level, lower suppuration and recession, less bone loss, and a reduction in total bacterial counts. In the treatment of peri-implantitis, the systemic antibiotic application reduces neither PPD nor BoP. Therefore, the systemic administration of antibiotics, in the case of peri-implantitis, should be rethought in light of the present results, contributing to address the problem of increasing antibiotic resistance.

Diagnosis and Management of Furcation Lesions in Dogs - A Review

The furcation is the anatomic area where the roots divide on a multirooted tooth. Periodontal disease causing alveolar bone loss can lead to furcation lesions of various stages. Once furcation involvement has occurred, the area can be more difficult to clean or treat due to the complex anatomy and morphology of furcations. Teeth with short root trunks, longer tooth roots, and roots with wide furcation entrance areas/degrees of separation and wide root divergence are considered better candidates for long term maintenance. Dog teeth possess many of these advantageous anatomic features compared to human teeth. Treatment options for teeth with furcation lesions include: closed debridement, open debridement, furcation plasty, tunneling, partial tooth or root resection, root separation (hemisection or trisection), regenerative therapies, or exodontia. There are many factors to consider in determining treatment options. The favorable and unfavorable characteristics for maintenance of teeth with furcation lesions are summarized. Home care and ongoing professional care are important aspects of periodontal disease control for any patient. Studies of systemic and local antibiotic therapies in human patients have not demonstrated reduction of furcation stages, and probiotic effects at furcation sites have not been specifically examined. Human review studies show that most molar teeth once deemed "hopeless" due to stage 3 furcation lesions can be maintained for at least 5 to 15 years with supportive periodontal therapy. Similar long term studies in dogs are needed to improve the evidence-based management of canine patients with furcation lesions.

Recurrence and progression of periodontitis and methods of management in long-term care: A systematic review and meta-analysis

AIM

To systematically review the literature to evaluate the recurrence of disease of people in long-term supportive periodontal care (SPC), previously treated for periodontitis, and determine the effect of different methods of managing recurrence. The review focused on stage IV periodontitis.

MATERIALS AND METHODS

An electronic search was conducted (until May 2020) for prospective clinical trials. Tooth loss was the primary outcome.

RESULTS

Twenty-four publications were retrieved to address recurrence of disease in long-term SPC. Eight studies were included in the meta-analyses for tooth loss, and three studies for disease progression/recurrence (clinical attachment level [CAL] loss ≥2 mm). For patients in SPC of 5-20 years, prevalence of losing more than one tooth was 9.6% (95% confidence interval [CI] 5%-14%), while experiencing more than one site of CAL loss ≥2 mm was 24.8% (95% CI 11%-38%). Six studies informed on the effect of different methods of managing recurrence, with no clear evidence of superiority between methods. No data was found specifically for stage IV periodontitis.

CONCLUSIONS

A small proportion of patients with stage III/IV periodontitis will experience tooth loss in long-term SPC (tendency for greater prevalence with time). Regular SPC appears to be important for reduction of tooth loss. No superior method to manage disease recurrence was found.

Pocket closure and residual pockets after non-surgical periodontal therapy: A systematic review and meta-analysis

Aim

To analyse the efficacy of non‐surgical therapy (NST) in terms of pocket closure (PC) and changes in percentage and number of pockets.

Materials and Methods

Three databases (PubMed, EMBASE, and Scopus) were searched up to January 2020. Prospective studies with a minimum follow‐up of 12 months and presenting data in terms of PC or number or percentage of pocket depths (PDs) before and after NST on systemically healthy patients were included. Random‐effect meta‐analyses were performed.

Results

After screening 4610 titles and abstracts, 27 studies were included. Of these, 63.9% of PC was reported by one study. The percentage of PDs ≤3 mm changed from 39.06% to 64.11% with a weighted mean difference (WMD) of 26.14% (p < .001). This accounted for a relative increase of healthy sites of 64.13%. The mean percentage of PD ≥5 mm was 28.23% and 11.71% before and after treatment, respectively, with a WMD of 15.50% (p < .001). The WMD in the number of PDs ≥5 mm before and after treatment was 24.42 (p = .036). The mean number of residual PPD ≥5 after NST was 14.13.

Conclusions

NST is able to eradicate the majority of the pockets. However, residual pockets after NST may remain and should be considered cautiously for further treatment planning.

Long-term assessment of periodontal disease progression after surgical or non-surgical treatment: a systematic review

The primary aim of this systematic review was to assess the evidence on periodontal disease progression after treatment in patients receiving supportive periodontal therapy (SPT) and to identify predictors of clinical attachment level (CAL) loss. A protocol was developed to answer the following focused question: In adult patients treated for periodontitis, what is the disease progression in terms of CAL loss after surgical or non-surgical treatment? Randomized controlled clinical trials, prospective cohort studies, and longitudinal observational human studies with a minimum of 5 years of follow-up after surgical or non-surgical treatment that reported CAL and probing depth changes were selected. Seventeen publications reporting data from 14 investigations were included. Data from 964 patients with a follow-up range of 5-15 years was evaluated. When the CAL at the latest follow-up was compared to the CAL after active periodontal therapy, 10 of the included studies reported an overall mean CAL loss of ≤0.5 mm, 3 studies reported a mean CAL loss of 0.5-1 mm, and 4 studies reported a mean CAL loss of >1 mm. Based on 7 publications, the percentage of sites showing a CAL loss of ≥2 mm varied from 3% to 20%, and a high percentage of sites with CAL loss was associated with poor oral hygiene, smoking, and poor compliance with SPT. The outcomes after periodontal therapy remained stable over time. Disease progression occurred in a reduced number of sites and patients, mostly associated with poor oral hygiene, poor compliance with SPT, and smoking.

Site-level progression of periodontal disease during a follow-up period

Periodontal disease is assessed and its progression is determined via observations on a site-by-site basis. Periodontal data are complex and structured in multiple levels; thus, applying a summary statistical approach (i.e., the mean) for site-level evaluations results in loss of information. Previous studies have shown the availability of mixed effects modeling. However, clinically beneficial information on the progression of periodontal disease during the follow-up period is not available.

We conducted a multicenter prospective cohort study. Using mixed effects modeling, we analyzed 18,834 sites distributed on 3,139 teeth in 124 patients, and data were collected 5 times over a 24-month follow-up period. The change in the clinical attachment level (CAL) was used as the outcome variable. The CAL at baseline was an important determinant of the CAL changes, which varied widely according to the tooth surface. The salivary levels of periodontal pathogens, such as Porphyromonas gingivalis and Aggregatibacter actinomycetemcomitans, were affected by CAL progression. “Linear”- and “burst”-type patterns of CAL progression occurred simultaneously within the same patient. More than half of the teeth that presented burst-type progression sites also presented linear-type progression sites, and most of the progressions were of the linear type. Maxillary premolars and anterior teeth tended to show burst-type progression. The parameters identified in this study may guide practitioners in determining the type and extent of treatment needed at the site and patient levels. In addition, these results show that prior hypotheses concerning "burst" and "linear" theories are not valid.

Systemic antibiotics in the treatment of periodontitis

Despite the fact that several clinical studies have shown additional benefits when certain systemic antibiotics are used as adjuncts to periodontal treatment, clear guidelines for the use of these agents in the clinical practice are not yet available. Basic questions concerning the use of systemic antibiotics to treat periodontitis remain unanswered, such as: which drug(s) should be used; which patients would most benefit from treatment; which are the most effective protocols (i.e. doses and durations); and in which phase of the mechanical therapy should the drug(s) be administered? Although not all of those questions have been directly addressed by controlled randomized clinical trials, recent concepts related to the ecology of periodontal diseases, as well as the major advances in laboratory and clinical research methods that have occurred in the past decade, have significantly broadened our knowledge in this field. This article endeavored to provide a 'state of the art' overview on the use of systemic antibiotics in the treatment of periodontitis, based on the most recent literature on the topic as well as on a compilation of data from studies conducted at the Center of Clinical Trials at Guarulhos University (São Paulo, Brazil) from 2002 to 2012.

Systematic review and meta-analysis on the nonsurgical treatment of chronic periodontitis by means of scaling and root planing with or without adjuncts

BACKGROUND

Conduct a systematic review and meta-analysis on nonsurgical treatment of patients with chronic periodontitis by means of scaling and root planing (SRP) with or without adjuncts.

METHODS

A panel of experts convened by the American Dental Association Council on Scientific Affairs conducted a search of PubMed (MEDLINE) and Embase for randomized controlled trials of SRP with or without the use of adjuncts with clinical attachment level (CAL) outcomes in trials at least 6 months in duration and published in English through July 2014. The authors assessed individual study bias by using the Cochrane Risk of Bias Tool and conducted meta-analyses to obtain the summary effect estimates and their precision and to assess heterogeneity. The authors used funnel plots and Egger tests to assess publication bias when there were more than 10 studies. The authors used a modified version of the US Preventive Services Task Force methods to assess the overall level of certainty in the evidence.

RESULTS

The panel included 72 articles on the effectiveness of SRP with or without the following: systemic antimicrobials, a systemic host modulator (subantimicrobial-dose doxycycline), locally delivered antimicrobials (chlorhexidine chips, doxycycline hyclate gel, and minocycline microspheres), and a variety of nonsurgical lasers (photodynamic therapy with a diode laser, a diode laser, neodymium:yttrium-aluminum-garnet lasers, and erbium lasers).

CONCLUSIONS AND PRACTICAL IMPLICATIONS

With a moderate level of certainty, the panel found approximately a 0.5-millimeter average improvement in CAL with SRP. Combinations of SRP with assorted adjuncts resulted in a range of average CAL improvements between 0.2 and 0.6 mm over SRP alone. The panel judged the following 4 adjunctive therapies as beneficial with a moderate level of certainty: systemic subantimicrobial-dose doxycycline, systemic antimicrobials, chlorhexidine chips, and photodynamic therapy with a diode laser. There was a low level of certainty in the benefits of the other included adjunctive therapies. The panel provides clinical recommendations in the associated clinical practice guideline.

Surgical and Non-Surgical Procedures Associated with Recurrence of Periodontitis in Periodontal Maintenance Therapy: 5-Year Prospective Study

Background and Objective

Prospective studies that investigated the influence of surgical and nonsurgical procedures in the recurrence of periodontitis and tooth loss in periodontal maintenance therapy (PMT) programs have not been previously reported. The objective of this study was to evaluate longitudinally the recurrence of periodontitis in regular compliers (RC) and irregular compliers (IC) individuals undergoing surgical and non-surgical procedures over 5 years in a program of PMT.

Materials and Methods

A total of 212 individuals participated in this study. Full-mouth periodontal examination including bleeding on probing, probing depth, and clinical attachment level were determined at all PMT visits over 5 years. The recurrence of periodontitis was evaluated in RC and IC individuals undergoing surgical and non-surgical procedures in PMT. The influences of risk variables of interest were tested through univariate analysis and multivariate logistic regression.

Results

Recurrence of periodontitis was significantly lower among RC when compared to IC. Individuals with recurrence of periodontitis and undergoing surgical procedures showed higher probing depth and clinical attachment loss than those who received non-surgical procedures. Recurrence of periodontitis was higher in individual undergoing surgical procedures and irregular compliance during PMT.

Conclusions

Irregular compliance and surgical procedures in individuals undergoing PMT presented higher rates of recurrence of periodontitis when compared to regular compliant patients undergoing non-surgical procedures.

Non-surgical periodontal therapy with systemic antibiotics in patients with untreated chronic periodontitis: a systematic review and meta-analysis

OBJECTIVE

The purpose of this meta-analysis is to evaluate the effectiveness of different systemic antibiotics in combination with scaling and root planing (SRP) when compared to SRP alone in patients with untreated chronic periodontitis.

BACKGROUND

Although chronic periodontitis is mostly treated without adjunctive systemic antibiotics, some recent meta-analyses have shown clinical benefit for some systemic antibiotics when used as an adjunct to SRP. However, there is a wide variety of systemic antibiotic regimens used today. It remains unclear if the selected type of systemic antibiotic influences the magnitude of clinical benefit.

MATERIAL AND METHODS

The MEDLINE-PubMed database was searched from their earliest records through May 16, 2013. Several journals were hand searched and some authors were contacted for additional information. Outcome measures analysed were mean bleeding on probing change, mean clinical attachment level gain and mean probing pocket depth reduction. Extracted data were pooled using a random effect model. Weighted mean differences were calculated and heterogeneity was assessed.

RESULTS

The search yielded 281 abstracts. Ultimately, 95 studies were selected, describing 43 studies meeting the eligibility criteria. Systemic antibiotics showed a significant (p < 0.05) additional pocket depth reduction for moderate (at 3 mo 0.27 mm ± 0.09, at 6 mo 0.23 mm ± 0.10 and at 12 mo 0.25 mm ± 0.27) and deep pockets (at 3 mo 0.62 mm ± 0.17, at 6 mo 0.58 mm ± 0.16 and at 12 mo 0.74 mm ± 0.30). Statistically, no specific type of antibiotic was superior over another. However, when analysing the clinical data for initially moderate pockets or deep pockets, some trends became apparent.

CONCLUSION

Systemic antibiotics combined with SRP offer additional clinical improvements compared to SRP alone. Although there were no statistically significant differences, there was a trend that for initially moderate and deep pockets, metronidazole or metronidazole combined with amoxicillin, resulted in clinical improvements that were more pronounced over doxycycline or azithromycin. Additionally, there was a trend that the magnitude of the clinical benefit became smaller over time (1 year).

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.

Effect of periodontal therapy on the subgingival microbiota over a 2-year monitoring period. I. Overall effect and kinetics of change

AIM

To examine the 2-year post-therapy kinetics of change in the composition of subgingival biofilms.

MATERIAL AND METHODS

In this study, 178 chronic periodontitis subjects were recruited and clinically monitored at baseline, 3, 6, 12, 18 and 24 months after therapy. All subjects received scaling and root planing and 156 one or more of periodontal surgery, systemically administered amoxicillin + metronidazole or local tetracycline at pockets ≥5 mm. Subgingival biofilm samples taken from each subject at each time point were analysed for their content of 40 bacterial species using checkerboard DNA-DNA hybridization. The significance of changes in median species counts over time was sought using the Wilcoxon or Friedman tests and adjusted for multiple comparisons.

RESULTS

Mean counts were significantly reduced from baseline to 2 years for 30 of the 40 taxa. Marked reductions were observed for periodontal pathogens including Tannerella forsythia, Treponema denticola and Eubacterium nodatum. The kinetics of change differed from species to species. When data were subset according to baseline PD, patterns of change in the microbial profiles were generally similar.

CONCLUSION

Periodontal therapy leads to a rapid reduction in periodontal pathogens, followed by a slower reduction in other taxa that can be sustained for at least 2 years.

Control of periodontal infections: a randomized controlled trial I. The primary outcome attachment gain and pocket depth reduction at treated sites

OBJECTIVE

To compare the treatment outcome of scaling and root planing (SRP) in combination with systemic antibiotics, local antibiotic therapy and/or periodontal surgery.

MATERIAL AND METHODS

One hundred and eighty-seven patients were assigned to eight groups treated by SRP plus none, one, two or three adjunctive treatments and monitored for 24 months in a randomized controlled clinical trial using a 2 × 2 × 2 factorial design. Systemic amoxicillin + metronidazole (SMA), local tetracycline delivery (LTC) and periodontal surgery (SURG) were evaluated as adjuncts. Changes in clinical attachment level (CAL) and probing pocket depth (PPD) were statistically evaluated by ancova of main effects.

RESULTS

Effects of adjunctive therapy to SRP were minimal at 3 months. Between 3 and 6 months PPD reduction occurred particularly in patients receiving periodontal surgery. After 6 months, both CAL gain and PPD reduction reached a plateau that was maintained at 24 months in all groups. The 24-month CAL gain was improved by SMA (0.50 mm) while PPD was reduced by SMA (0.51 mm) and SURG (0.36 mm). Smoking reduced CAL gain and PPD reduction.

CONCLUSION

Patients receiving adjunctive therapies generally exhibited improved CAL gain and/or PPD reduction when compared with the outcome of SRP alone. Only additive, not synergistic effects of the various adjunctive therapies were observed.

Clinical changes following four different periodontal therapies for the treatment of chronic periodontitis: 1-year results

OBJECTIVE

To compare clinical changes occurring in chronic periodontitis subjects receiving SRP alone or with systemically administered azithromycin, metronidazole or a sub-antimicrobial dose of doxycycline.

MATERIAL AND METHODS

92 chronic periodontitis subjects were randomly assigned to receive SRP alone (N=23) or combined with 500 mg azithromycin per day for 3 days (N=25), 250 mg metronidazole tid for 14 days (N=24) or 20 mg doxycycline bid for 3 months (N=20). Gingival redness, bleeding on probing, suppuration, pocket depth and attachment level were measured at baseline and 3, 6 and 12 months post therapy. The significance of changes in clinical parameters within groups over time was sought using the Friedman test and among groups using ANCOVA or the Kruskal Wallis test.

RESULTS

All groups showed clinical improvements at 12 months, with subjects receiving adjunctive agents showing a somewhat better response. Sites with initial pocket depth > 6 mm showed significantly greater pocket depth reduction and greater attachment gain in subjects receiving metronidazole or azithromycin than subjects in the other groups. Some subjects showed attachment loss at 12 months in each group ranging from 15% to 39% of subjects in the SDD and SRP only groups respectively.

CONCLUSION

This study, demonstrated that periodontal therapy provides clinical benefits and that antibiotics provide a clinical benefit over SRP alone, particularly at initially deeper periodontal pockets.

Systemic doxycycline and nonsurgical periodontal treatment in diabetic patients

DESIGN

This was a randomised controlled trial (RCT).

INTERVENTION

Group 1 (30 patients) was given oral-hygiene instruction, scaling and root planing, chlorhexidine rinses twice a day and doxycycline (100 mg/day for 15 days). Group 2 (30 patients) had the same treatment but without doxycycline.

OUTCOME MEASURE

Plaque index (PI), probing pocket depth (PPD), clinical attachment levels (CAL) and bleeding on probing (BOP) were recorded.

RESULTS

Both groups had a measurable improvement in all periodontal parameters, since PI, BOP, PPD and CAL were reduced. The reduction in PPD of 6 mm and in BOP became statistically significant when doxycycline was used (group 1), however.

CONCLUSIONS

Although both periodontal treatment regimens are effective in type-1 diabetics, the use of doxycycline as an adjunct provided more significant results when good plaque control was achieved.

Proportion of antibiotic resistance in subgingival plaque samples from Mexican subjects

AIM

To determine the proportion of bacteria resistant to amoxicillin and doxycycline in subgingival plaque samples from Mexican subjects.

MATERIALS AND METHODS

Two subgingival plaque samples were taken from 20 Mexican subjects. Samples were dispersed, diluted and plated on non-antibiotic agar plates and on plates containing 0.5, 1, 2, 4, 8 and 16 microg/ml of either amoxicillin or doxycycline. The proportion of resistant bacteria was calculated based on the total number of colony-forming units present in the non-antibiotic containing plates.

RESULTS

On average, 0.4-13.4% and 0.9-20.4% of the total cultivable subgingival microbiota was resistant to the concentrations tested of amoxicillin and doxycycline, respectively. The differences between antibiotics were statistically significant for the 0.5, 2 and 4 mug/ml concentrations (p < 0.05, Wilcoxon's test).

CONCLUSIONS

Our findings revealed that a relatively small proportion of the total cultivable subgingival microbiota from Mexican subjects was resistant to amoxicillin and doxycycline.

Systemic antibiotics in periodontics

This position paper addresses the role of systemic antibiotics in the treatment of periodontal disease. Topical antibiotic therapy is not discussed here. The paper was prepared by the Research, Science and Therapy Committee of the American Academy of Periodontology. The document consists of three sections: 1) concept of antibiotic periodontal therapy; 2) efficacy of antibiotic periodontal therapy; and 3) practical aspects of antibiotic periodontal therapy. The conclusions drawn in this paper represent the position of the American Academy of Periodontology and are intended for the information of the dental profession.

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

BACKGROUND

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

RATIONALE

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

SEARCH PROTOCOL

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

SELECTION CRITERIA

INCLUSION CRITERIA

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

EXCLUSION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

REVIEWERS' CONCLUSIONS

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

Systemic anti-infective periodontal therapy. A systematic review

BACKGROUND

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

RATIONALE

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

FOCUSED QUESTION

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

SEARCH PROTOCOL

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

SELECTION CRITERIA

INCLUSION CRITERIA

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

EXCLUSION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

REVIEWERS' CONCLUSIONS

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

Specific Antibiotics in the Treatment of Periodontitis – A Proposed Strategy

BACKGROUND

The purpose of the present study was to propose a strategy for the selection of antibiotics that specifically target complexes of periodontal pathogens present in patients with periodontitis.

METHODS

Seven hundred seventy-four (774) patients with various forms of periodontitis were included in the study. Subgingival plaque samples were taken from the deepest periodontal pockets in each quadrant using a sterile curet, and pooled. Actinobacillus actinomycetemcomitans, Porphyromonas gingivalis, Eikenella corrodens, Tannerella forsythensis, Prevotella intermedia, and Prevotella nigrescens were identified by polymerase chain reaction, and the prevalence of combinations of these pathogens was determined. To each pathogen complex (PC), i.e., combination of pathogens, those antibiotics were assigned that were most specific according to the published minimum inhibitory concentration (MIC90) values and the gingival crevicular fluid (GCF) concentrations achievable in vivo. Antibiotic GCF concentrations had to be at least 10 times the MIC90 values, and the narrowest spectrum was selected with respect to the assessed periodontal pathogens.

RESULTS

Nine major PCs (each > or = 3% of all patients) were found in 73.4% of all patients, whereas 38 minor PCs (each < 3% of all patients) were distributed in 26.6% of all patients. Ten different antibiotic regimens were found to be specific for the total of 46 PCs; i.e., metronidazole and amoxicillin in 11 PCs (55.0% of all patients), metronidazole and amoxicillin/clavulanic acid or metronidazole and ciprofloxacin in 13 PCs (18.9%), amoxicillin in 4 PCs (8.3%), doxycycline in 2 PCs (6.1%), metronidazole in 8 PCs (4.1%), amoxicillin/clavulanic acid in 3 PCs (2.9%), clindamycin in 2 PCs (1.5%), ciprofloxacin in 2 PCs (0.4%), and tetracycline in 1 PC (0.3%).

CONCLUSION

The results of the study indicate that there are at least 46 different combinations of the assessed periodontal pathogens in subjects with periodontitis, and at least 10 different antibiotic regimens might be required to specifically target the various pathogen complexes.

Change of antibiotic susceptibility following periodontal therapy. A pilot study in aggressive periodontal disease

BACKGROUND

The hypothesis was tested that bacterial susceptibilities in aggressive periodontitis change upon administration of systemic antibiotics as adjuncts to periodontal therapy.

METHODS

In 23 subjects (average age 38.9+/-6.7 years) with aggressive periodontitis, microbial parameters were assessed prior to and 1 year after completion of comprehensive mechanical/surgical and systemic antimicrobial therapy. Following identification of five selected pathogens with the Rapid ID 32 A system, their susceptibilities towards amoxicillin/clavulanate potassium, metronidazole, and tetracycline were examined with the E-test. Antibiotics were administered according to the test results, and the minimal inhibitory concentrations (MIC90) were reevaluated after 1 year. Statistical analysis was performed on a patient basis, with the site data used for evaluation of the MIC levels.

RESULTS

Bacterial MIC levels remained constant among the three antibiotic treatment groups compared with baseline. Mean MIC90 values ranged from <0.02 to 0.11 microg/ml (amoxicillin/clavulanate potassium), <0.02 to 0.27 microg/ml (metronidazole), and <0.02 to 0.11 microg/ml (tetracycline). Observed changes in susceptibility were attributed to the elimination of single bacterial taxa in the subgingival environment after antibiotic therapy. There were no statistically significant differences in clinical parameters among the treatment groups. Single tetracycline MICs were 1.5- to 6-fold enhanced compared to amoxicillin/clavulanate potassium and metronidazole.

CONCLUSION

The periodontal pathogens investigated prior to and 1 year after periodontal therapy are tested sensitive to the antimicrobial agents. In aggressive periodontitis, changes in bacterial susceptibility upon the administration of systemic antibiotics are associated with the limited number of isolates tested following therapy.

The use of PVP-iodine as an adjunct to non-surgical treatment of chronic periodontitis

OBJECTIVE

The present study was performed to assess the effect of topically-applied PVP-iodine, used as an adjunct both during basic non-surgical therapy and at re-treatment during the long-term maintenance of patients with advanced periodontal disease.

MATERIAL AND METHODS

223 patients with advanced destructive periodontitis were recruited. The participants met the following inclusion criteria: (i) a minimum of 8 non-molar teeth, (ii) probing pocket depth of > or = 6 mm at > or = 2 teeth in each dentate quadrant, and radiographic bone loss exceeding 40% at the same teeth. A baseline I examination included assessment of plaque, gingivitis, probing pocket depth (PPD), probing attachment level (PAL) and radiographic bone height (RxBL). Following baseline I, the patients were stratified into 2 treatment groups; 2 subjects out of 3 were included in a control group and 1 in a test group. All participants, on an individual basis, received a case presentation and were instructed in proper self-performed plaque control measures. Non-surgical therapy was performed by the use of an ultrasonic device. The instrumentation in the test group was combined with the administration of 0.1% PVP-iodine. All subjects were recalled for comprehensive examinations 3, 6 and 12 months (baseline II) after baseline I and then after 3, 5 and 13 years of maintenance therapy. PAL determinations were performed annually. Subjects (losers) who at the re-examinations after 1, 2 and 3 years of maintenance demonstrated an annual further loss of PAL > or = 2 mm at > or = 4 teeth were exited from the study and referred for re-treatment. There were 9 losers in the test and 31 in the control group. In addition, 8 subjects in the test and 25 subjects in the control group withdrew from the trial for reasons unrelated to the study. These 73 subjects were not included in the data presentation from the various examinations.

RESULTS

It was demonstrated that non-surgical periodontal therapy resulted in (i) improved gingival conditions, (ii) reduced PPD, (iii) gain in PAL. It was also documented that the topical application of 0.1% PVP-iodine in conjunction with the mechanical root debridement established conditions which further improved the outcome of therapy. This was evidenced by the fact that at the 3, 6, and 12 months re-examinations after baseline I, the test group had significantly lower mean PPD values and significantly more gain of PAL than the control group. During the 12 years of SPT, it was possible for most subjects in both groups to maintain shallow pockets and to avoid marked further loss of PAL. There were, however, a larger number of losers in the control than in the test group.

CONCLUSION

PVP-iodine, topically applied during subgingival instrumentation, may improve the outcome of non-surgical periodontal therapy.

Initial outcome and long-term effect of surgical and non-surgical treatment of advanced periodontal disease

AIM

A clinical trial was performed to determine (i) the initial outcome of non-surgical and surgical access treatment in subjects with advanced periodontal disease and (ii) the incidence of recurrent disease during 12 years of maintenance following active therapy.

MATERIAL AND METHODS

Each of the 64 subjects included in the trial showed signs of (i) generalized gingival inflammation, (ii) had a minimum of 12 non-molar teeth with deep pockets (> or =6 mm) and with > or =6 mm alveolar bone loss. They were randomly assigned to 2 treatment groups; one surgical (SU) and one non-surgical (SRP). Following a baseline examination, all patients were given a detailed case presentation which included oral hygiene instruction. The subjects in SU received surgical access therapy, while in SRP non-surgical treatment was provided. After this basic therapy, all subjects were enrolled in a maintenance care program and were provided with meticulous supportive periodontal therapy (SPT) 3-4 times per year. Sites that at a recall appointment bled on gentle probing and had a PPD value of > or =5 mm were exposed to renewed subgingival instrumentation. Comprehensive re-examinations were performed after 1, 3, 5 and 13 years of SPT. If a subject between annual examinations exhibited marked disease progression (i.e., additional PAL loss of > or =2 mm at > or =4 teeth), he/she was exited from the study and given additional treatment.

RESULTS

It was observed that (i) surgical therapy (SU) was more effective than non-surgical scaling and root planing (SRP) in reducing the overall mean probing pocket depth and in eliminating deep pockets, (ii) more SRP-treated subjects exhibited signs of advanced disease progression in the 1-3 year period following active therapy than SU-treated subjects.

CONCLUSION

In subjects with advanced periodontal disease, surgical therapy provides better short and long-term periodontal pocket reduction and may lead to fewer subjects requiring additional adjunctive therapy.