Cost-effectiveness of adjunctive antimicrobials in the treatment of periodontitis

The effectiveness of autologous platelet-rich concentrates as an adjunct during nonsurgical periodontal therapy: a systematic review and meta-analysis of randomized controlled trials

OBJECTIVES

To evaluate the efficacy of autologous platelet concentrates (APC) on periodontal outcomes in nonsurgical therapy of periodontitis patients.

METHOD

Electronic search via Web of Science, MEDLINE via PubMed, Scopus, and Cochrane CENTRAL registry as well as manual search were done from June 2024 to July 2024 for relevant publication from inception until June 2024. The articles were assessed by 2 independent reviewers and deemed relevant when the interventional studies reported on periodontal outcomes after adjunctive APC were used in NSPT. The studies were excluded if it was not in English or unpublished. The risk of bias for each study was assessed using the Cochrane risk-of-bias tool (RoB 2). Fixed effect meta-analysis was conducted to measure the summary effect for change of periodontal pocket depth (PPD) and Clinical Attachment Level (CAL). The statistical heterogeneity between studies was also calculated using I2 test.

RESULT

A total of 607 records were found in the four electronic databases. Following the removal of duplicates and initial title screening, 16 full text articles from electronic search and 7 articles from manual search were assessed resulting in 13 studies included in the systematic review. The overall risk of bias showed most studies have moderate to high risk of bias. The fixed-effect meta-analysis showed summary effects favored the adjunctive use of APC in nonsurgical periodontal therapy but with high heterogeneity between the studies, particularly for CAL.

CONCLUSION

The evidence on APC as adjunct in NSPT is limited by the small number of studies, moderate to high risk of bias in most studies and significant heterogeneity in the results.

Impact of smoking on cost-effectiveness of 10-48 years of periodontal care

The study aims were (1) to explore whether "periodontal treatment" consisting of surgical therapy (flap, resective, or regenerative) or scaling and root planing treatment with long-term periodontal maintenance treatment, is cost-effective in terms of preventing periodontitis-attributable tooth extraction and replacement by implant-supported crowns ("extraction/replacement"); (2) to assess the effect of cigarette smoking on this cost-effectiveness. Data for this observational retrospective study were collected from dental charts of patients who had received periodontal therapy and at least annual follow-up visits for >10 years were analyzed by linear regression generalized estimating equations and generalized linear models. Among 399 adults (199 males, 200 females), those with the least mean annual treatment cost experienced the greatest mean annual costs for extraction/replacement, indicating general cost-effectiveness. Cigarette smoking adversely impacted this cost-effectiveness, with current heavy smokers experiencing no cost-effectiveness. Former smokers with Grade C periodontitis benefitted most, whereas smoking did not influence cost-effectiveness for Grade B periodontitis. Assessed by mean annual costs of "extraction/replacement," periodontal treatment was cost-effective, which decreased in a dose-response manner by former and current smoking intensity. Cigarette smoking should be factored into treatment planning and cost-effective analyses of periodontal treatment. Smoking cessation should be encouraged.

Cost-effectiveness and cost-utility analyses of three different gargles in the treatment of chronic periodontitis

OBJECTIVE

This study aimed to investigate the economics of three different gargles in the treatment of chronic periodontitis.

METHODS

A total of 108 patients with periodontitis received one of the following three gargles: xipayi, compound chlorhexidine, or Kangfuxin gargle. The basic information of the patients, the costs of the gargles, the periodontal indexes before and after treatment, and the scores of the 3-level version of the EuroQol Five Dimensions Questionnaire were collected. The cost-effectiveness and cost-utility of the various gargles were determined.

RESULTS

The cost-effectiveness ratios (CER) of the three groups after treatment were 1828.75, 1573.34, and 1876.92 RMB, respectively. The utility values before treatment were 0.92, 0.90, and 0.91, respectively, and the utility values after treatment were 0.98, 0.98, and 0.97, respectively. The cost-utility ratios (CURs) were 213.43, 195.61, and 301.53 RMB, respectively.

CONCLUSIONS

For each increase in effective rate and quality-adjusted life years, the treatment cost of periodontitis patients was lower than the gross domestic product per capita of Jiangsu Province, indicating that the treatment cost is completely worth it. The CER and CUR results were the same, and the compound chlorhexidine group was the lowest, demonstrating that when the same therapeutic effect was achieved, it cost the least.

The economic and societal impact of periodontal and peri-implant diseases

Periodontal and peri-implant diseases result from a chronic inflammatory response to dysbiotic microbial communities and are characterized by inflammation in the soft tissue and the ensuing progressive destruction of supporting bone, resulting in tooth or implant loss. These diseases' high prevalence, multifactorial etiology, extensive treatment costs, and significant detriment to patients' quality-of-life underscore their status as a critical public health burden. This review delineates the economic and sociocultural ramifications of periodontal and peri-implant diseases on patient welfare and healthcare economics. We delve into the implications of diagnosis, treatment, supportive care, and managing destructive tissue consequences, contrasting these aspects with healthy patients.

Efficacy of Proanthocyanidins in Nonsurgical Periodontal Therapy

BACKGROUND

The aim of this work was to evaluate the efficacy of proanthocyanidins (PACNs) as an adjunctive periodontal therapy in patients with periodontitis.

METHODS

Patients with periodontitis (stage III-IV) were included in this randomised clinical study. Patients with periodontitis received 2 different treatment modalities: minimally invasive nonsurgical therapy only (MINST group) or minimally invasive nonsurgical therapy and subgingival application of collagen hydrogels with PACNs (MINST + PACNs group). Clinical periodontal parameters, that is, pocket probing depth (PPD), clinical attachment level (CAL), bleeding on probing (BOP), plaque index (PI), were evaluated before treatment and after 8 weeks. Concentrations of immunologic markers, matrix metalloproteinase-3 (MMP-3), and tissue inhibitor of matrix metalloproteinase-1 (TIMP-1) in saliva were assessed at baseline and at 8-week follow-up.

RESULTS

Forty-six patients diagnosed with periodontitis were randomised into 2 groups: 23 patients in the MINST group and 23 patients in the MINST + PACNs group received the intended treatment. PACNs combined with MINST resulted in additional statistically significant PPD reduction and CAL gain in moderate periodontal pockets by 0.5 mm (P < .05) on average compared to MINST alone. Additional use of PACNs did not result in additional statistically significant improvement of BOP or PI values. Application of PACNs showed significant reduction of MMP-3 levels in saliva after 8 weeks (P < .05).

CONCLUSIONS

Adjunctive use of PACNs in MINST resulted in better clinical outcomes for moderate pockets. Additional use of PACNs improved MMP-3 concentration in saliva more than MINST alone. Biochemical analysis revealed that MMP-3 concentration in saliva reflected the periodontal health state.

Risk of Periodontitis in Patients with Gastroesophageal Reflux Disease: A Nationwide Retrospective Cohort Study

Background: Gastroesophageal reflux disease (GERD) is the most common digestive clinical problem worldwide that affects approximately 20% of the adult populations in Western countries. Poor oral hygiene has been reported to be associated with GERD as an atypical clinical complication. However, evidence showing the relationship between GERD and the risk of periodontitis is less clear. The present study aimed to use a retrospective cohort study design to further clarify the association between GERD and the subsequent risk of periodontitis. Methods: The risk of periodontitis in patients with GERD was investigated by analyzing epidemiological data from the Taiwan National Health Insurance Research Database from 2008 to 2018. We selected 20,125 participants with a minimum age of 40 years in the GERD group and 1:1 propensity-matched these with non-GERD individuals by sex, age, and comorbidities. The incidence of periodontitis was determined at the end of 2018. A Cox proportional hazards regression model was used to evaluate the risk of periodontitis in patients with GERD. Results: The overall incidence rate of the periodontitis risk was 1.38-fold higher (30.0 vs. 21.7/1000 person years, adjusted hazard ratio (aHR) = 1.36, 95% confidence interval (CI) = 1.28−1.45) in patients with GERD than in those without GERD. After stratified analyses for sex, age, and comorbidity, patients with GERD had a higher risk of periodontitis for age (aHR = 1.31, 95% CI = 1.20−1.42 for 40−54 years and aHR = 1.42, 95% CI =1.28−1.57 for 55−69 years), sex (aHR = 1.40, 95% CI = 1.28−1.54 for men and aHR = 1.33, 95% CI = 1.23−1.45 for women), and presence (aHR = 1.36, 95% CI = 1.27−1.45) and absence (aHR = 1.40, 95% CI = 1.21−1.62) of comorbidity than those without GERD. Among the GERD cohort, the risk for periodontitis was increased with an increasing number of emergency room visits (≥ 1 vs. <1, aHR = 5.19, 95% CI = 2.16−12.5). Conclusions: Our results revealed that patients with GERD have a higher risk of periodontitis development than those without GERD. Clinicians should pay more attention to identifying and managing periodontitis in patients with GERD.

Oral Health, Antimicrobials and Care for Patients With Chronic Oral Diseases – A Review of Knowledge and Treatment Strategies

Periodontal and chronic oral mucosal diseases are significant life impacting conditions which may co-exist and synergistically act to cause more severe and widespread oral pathology with enhanced challenges in effective management. Clinicians regularly observe these effects and struggle to effectively manage both problems in many patients. There is limited understanding of many basic and applied scientific elements underpinning potentially shared aetiopathological features and management. Recent developments in translational science provide an opportunity to greater improve knowledge and subsequently care for patients with these problems.

Systemic azithromycin as an adjunct to scaling and root planing in patients with stage III/IV periodontitis: 12-month results of a randomized controlled clinical trial

OBJECTIVES

To determine whether azithromycin (AZI) as an adjunct to scaling and root planing (SRP), when compared to placebo, decreases the number of sites demonstrating pocket depth (PD) ≥ 5 mm and bleeding on probing (BOP) 12 months post-treatment in stage III/IV periodontitis patients.

MATERIALS AND METHODS

In a double-blind randomized parallel-arm placebo-controlled trial, 40 stage III/IV periodontitis patients received steps 1 and 2 of periodontal treatment in two sessions within 7 days. Patients then received systemic antibiotic therapy (n = 20; AZI 500 mg/day, 3 days) or placebo (n = 20). Additional instrumentation of residual diseased sites (DS) - sites with PD ≥ 5 mm and BOP - was performed at the 3-, 6- and 9-month follow-ups. The primary outcome variable was the number of DS at the 12-month re-evaluation. Using a multivariate multilevel logistic regression model, the effects of gender, age, antibiotic therapy, presence of Porphyromonas gingivalis or Aggregatibacter actinomycetemcomitans, smoking, tooth being a molar and interdental location were evaluated.

RESULTS

The number of DS after 12 months was similar in the test (median (Me) = 4, interquartile range (IQR) = 0-6) and control (Me = 3, IQR = 1-6.5) groups. Both groups showed substantial but equivalent improvements in periodontal parameters, with no intergroup differences at initially shallow or deep sites. The logistic regression showed a lower odds ratio (OR) for the healing of DS on molars (OR = 0.29; p < 0.001) and in smokers (OR = 0.36; p = 0.048).

CONCLUSION

Stage III/IV periodontitis patients showed significant but comparable improvements in periodontal parameters and the number of residual DS at the 12-month revaluation regardless of treatment type. This may have been the result of the additional instrumentation received by patients at residual DS in both treatment groups.

CLINICAL RELEVANCE

Treatment with AZI + SRP provided no additional benefits after 12 months in terms of periodontal parameters or the number of persisting sites with PD ≥ 5 mm + BOP as compared to SRP plus placebo.

TRIAL REGISTRATION

EUDRA-CT: 2015-004306-42; https://www.clinicaltrialsregister.eu/ctr-search/trial/2015-004306-42/SI , registered 17. 12. 2015.

Economic evaluations in the treatment and evaluation of patients with periodontal disease: A critical review

AIM

To evaluate the types and quality of reporting of economic evaluations carried out in the clinical management of periodontal disease over 32 years from 1987 to 2019.

MATERIAL AND METHODS

A systematic search of articles from 1987 to 2019 was conducted using PubMed, Web of Science, The Cochrane Central Register of Controlled Trials, Health Technology Assessment Database and Embase. The quality of the economic evaluations was assessed based on the Consolidated Health Economic Evaluation Reporting Standard checklist. Due to considerable between-study heterogeneity, a meta-analysis was not performed.

RESULTS

Twenty one publications were included. 11 studies used cost-effectiveness analysis, five used cost-minimization analysis, four used cost-utility analysis and two used cost-benefit analysis. Comparators, choice of health outcomes, estimating resources and costs were fully reported in all studies. Many studies had inadequate reporting in terms of estimating resources and costs, choice of health outcomes, characterizing heterogeneity and study perspective.

CONCLUSIONS

There has been an increase in health economics studies in the field of clinical periodontology over the past decade. Several studies did not report study perspective, and the health outcomes chosen were not relevant for some studies. Future studies should follow an economic evaluation checklist for high-quality reporting and consistency.

Commercial Local Pharmacotherapeutics and Adjunctive Agents for Nonsurgical Treatment of Periodontitis: A Contemporary Review of Clinical Efficacies and Challenges

Periodontal infections tend to be site-specific, mostly confined to the periodontal pocket. With the surge of antibiotic-resistant bacteria, the trend is shifting towards other therapeutic modalities, especially locally delivered approaches that include other pharmacotherapeutic drugs and medical devices. This narrative review aimed to provide insights into the clinical efficacy of local drug delivery and adjunctive agents used in nonsurgical management of periodontitis. Electronic (PubMed/MEDLINE, CENTRAL, and EMBASE) and bibliographic searches of past systematic reviews were carried out to identify previous publications on the topic. Only relevant literature and randomized controlled trials published in English were selected. In addition, a literature review was developed based on the selected articles. Experimental drugs or agents were excluded. This review highlights the clinically proven and commercially available therapeutic agents related to the management of periodontal disease with comparisons of their clinical efficacies and challenges. A vast array of commercial local pharmacotherapeutic agents had been clinically tested, but the methodologies and clinical results varied within and between each agent used, causing difficulty in drawing conclusions and providing support to the superiority of one agent over another. Considering the benefit-cost ratio with the modest clinical results, the long-term usefulness of these agents remains debatable.

Risk factors for recurrence of periodontal disease in patients in maintenance care in a private practice

AIM

To assess periodontal and dental conditions in individuals in maintenance care after periodontal therapy in private practice, and to identify risk factors for recurrence of disease and tooth loss.

MATERIALS AND METHODS

One hundred patients attending a routine recall visit were included. All had been treated for periodontal disease and were in maintenance since ≥ 2 years.

RESULTS

Examinations took place 18.0 (±8.71) years after the start of periodontal therapy. A total of 40.1 ± 22.5 recall visits were registered during this time. 91% of the participants had an initial diagnosis of chronic, 9% of aggressive periodontitis. The average participant was 46 years old and had 26 teeth. 283 of 2,549 initially present teeth were lost, half of them being molars. Periodontal and endo-periodontal complications accounted for only 16 lost teeth. The prevalence of all probing depth (PD) categories decreased significantly. The longer the time, the more frequent the recall visits, and the more was spent during the maintenance phase, the greater was the reduction. Multivariate analysis rendered BMI and smoking as factors influencing number of sites with PD ≥ 4 mm and bleeding on probing.

CONCLUSION

Tooth loss and periodontal tissue damage can be contained over prolonged periods if periodontal disease is treated and patients attend regular maintenance care.

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

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

Surgical treatment of the residual periodontal pocket

The ultimate goal of periodontal therapy is to prevent further disease progression in order to reduce the risk of tooth loss. This objective can be achieved through a number of therapeutic modalities comprising both the nonsurgical and surgical phases of periodontal therapy. Nonsurgical periodontal treatment has been shown to control periodontal infection and to arrest progression of the disease in a significant number of cases. However, despite completion of nonsurgical treatment, a number of periodontal pockets, defined as 'residual', often remain. The presence of residual pockets may jeopardize tooth survival and be a risk factor of further disease progression, and ultimately tooth loss. Therefore, the aim of this review is to analyze the knowledge available on the indications for and the performance of periodontal surgical treatment of residual pockets in terms of 'traditional' (clinical, microbiological), patient-based and systemic health outcomes.

National Economic Burden Associated with Management of Periodontitis in Malaysia

Objectives. The aim of this study is to estimate the economic burden associated with the management of periodontitis in Malaysia from the societal perspective. Methods. We estimated the economic burden of periodontitis by combining the disease prevalence with its treatment costs. We estimated treatment costs (with 2012 value of Malaysian Ringgit) using the cost-of-illness approach and included both direct and indirect costs. We used the National Oral Health Survey for Adults (2010) data to estimate the prevalence of periodontitis and 2010 national census data to estimate the adult population at risk for periodontitis. Results. The economic burden of managing all cases of periodontitis at the national level from the societal perspective was approximately MYR 32.5 billion, accounting for 3.83% of the 2012 Gross Domestic Product of the country. It would cost the nation MYR 18.3 billion to treat patients with moderate periodontitis and MYR 13.7 billion to treat patients with severe periodontitis. Conclusion. The economic burden of periodontitis in Malaysia is substantial and comparable with that of other chronic diseases in the country. This is attributable to its high prevalence and high cost of treatment. Judicious application of promotive, preventive, and curative approaches to periodontitis management is decidedly warranted.

Long-term evaluation of the antimicrobial susceptibility and microbial profile of subgingival biofilms in individuals with aggressive periodontitis

This study evaluates the antimicrobial susceptibility and composition of subgingival biofilms in generalized aggressive periodontitis (GAP) patients treated using mechanical/antimicrobial therapies, including chlorhexidine (CHX), amoxicillin (AMX) and metronidazole (MET). GAP patients allocated to the placebo (C, n = 15) or test group (T, n = 16) received full-mouth disinfection with CHX, scaling and root planning, and systemic AMX (500 mg)/MET (250 mg) or placebos. Subgingival plaque samples were obtained at baseline, 3, 6, 9 and 12 months post-therapy from 3–4 periodontal pockets, and the samples were pooled and cultivated under anaerobic conditions. The minimum inhibitory concentrations (MICs) of AMX, MET and CHX were assessed using the microdilution method. Bacterial species present in the cultivated biofilm were identified by checkerboard DNA-DNA hybridization. At baseline, no differences in the MICs between groups were observed for the 3 antimicrobials. In the T group, significant increases in the MICs of CHX (p < 0.05) and AMX (p < 0.01) were detected during the first 3 months; however, the MIC of MET decreased at 12 months (p < 0.05). For several species, the MICs significantly changed over time in both groups, i.e., Streptococci MICs tended to increase, while for several periodontal pathogens, the MICs diminished. A transitory increase in the MIC of the subgingival biofilm to AMX and CHX was observed in GAP patients treated using enhanced mechanical therapy with topical CHX and systemic AMX/MET. Both protocols presented limited effects on the cultivable subgingival microbiota.

Full mouth versus quadrant treatment in chronic periodontitis

AIM

The aim of this review is to discuss the evidence for the management of chronic periodontitis, including methods of non-surgical therapy such as full mouth disinfection, full mouth debridement and conventional quadrant-by-quadrant therapy.

METHODS

Manual searches of Medline and Embase databases provided the relevant studies.

RESULTS

Multiple randomised controlled trials (RCTs) selected for the paper failed to show any significant differences between the quadrant-wise treatment and full mouth debridement and modalities.

PRACTICAL IMPLICATIONS

This review demonstrates that there is no known difference in treatment outcomes between full mouth debridement and traditional quadrant therapy. Further RCTs are necessary to assess clinical effectiveness of chemical adjunct use.

Cost analysis of periodontitis management in public sector specialist dental clinics

BACKGROUND

The objective of this paper is to quantify the cost of periodontitis management at public sector specialist periodontal clinic settings and analyse the distribution of cost components.

METHODS

Five specialist periodontal clinics in the Ministry of Health represented the public sector in providing clinical and cost data for this study. Newly-diagnosed periodontitis patients (N = 165) were recruited and followed up for one year of specialist periodontal care. Direct and indirect costs from the societal viewpoint were included in the cost analysis. They were measured in 2012 Ringgit Malaysia (MYR) and estimated from the societal perspective using activity-based and step-down costing methods, and substantiated by clinical pathways. Cost of dental equipment, consumables and labour (average treatment time) for each procedure was measured using activity-based costing method. Meanwhile, unit cost calculations for clinic administration, utilities and maintenance used step-down approach. Patient expenditures and absence from work were recorded via diary entries. The conversion from MYR to Euro was based on the 2012 rate (1€ = MYR4).

RESULTS

A total of 2900 procedures were provided, with an average cost of MYR 2820 (€705) per patient for the study year, and MYR 376 (€94) per outpatient visit. Out of this, 90% was contributed by provider cost and 10% by patient cost; 94% for direct cost and 4% for lost productivity. Treatment of aggressive periodontitis was significantly higher than for chronic periodontitis (t-test, P = 0.003). Higher costs were expended as disease severity increased (ANOVA, P = 0.022) and for patients requiring surgeries (ANOVA, P < 0.001). Providers generally spent most on consumables while patients spent most on transportation.

CONCLUSIONS

Cost of providing dental treatment for periodontitis patients at public sector specialist settings were substantial and comparable with some non-communicable diseases. These findings provide basis for identifying potential cost-reducing strategies, estimating economic burden of periodontitis management and performing economic evaluation of the specialist periodontal programme.

Economics of periodontal care: market trends, competitive forces and incentives

The adoption of new technologies for the treatment of periodontitis and the replacement of teeth has changed the delivery of periodontal care. The objective of this review was to conduct an economic analysis of a mature periodontal service market with a well-developed workforce, including general dentists, dental hygienists and periodontists. Publicly available information about the delivery of periodontal care in the USA was used. A strong trend toward increased utilization of nonsurgical therapy and decreased utilization of surgical periodontal therapy was observed. Although periodontal surgery remained the domain of periodontists, general dentists had taken over most of the nonsurgical periodontal care. The decline in surgical periodontal therapy was associated with an increased utilization of implant-supported prosthesis. Approximately equal numbers of implants were surgically placed by periodontists, oral and maxillofacial surgeons, and general dentists. Porter's framework of the forces driving industry competition was used to analyze the role of patients, dental insurances, general dentists, competitors, entrants, substitutes and suppliers in the periodontal service market. Estimates of out-of-pocket payments of self-pay and insured patients, reimbursement by dental insurances and providers' earnings for various periodontal procedures and alternative treatments were calculated. Economic incentives for providers may explain some of the observed shifts in the periodontal service market. Given the inherent uncertainty about treatment outcomes in dentistry, which makes clinical judgment critical, providers may yield to economic incentives without jeopardizing their ethical standards and professional norms. Although the economic analysis pertains to the USA, some considerations may also apply to other periodontal service markets.

Periodontology: past, present, perspectives

Periodontitis is an infectious disease that affects the tooth-supporting tissues and exhibits a wide range of clinical, microbiological and immunological manifestations. The disease is associated with and is probably caused by a multifaceted dynamic interaction of specific infectious agents, host immune responses, harmful environmental exposure and genetic susceptibility factors. This volume of Periodontology 2000 covers key subdisciplines of periodontology, ranging from etiopathogeny to therapy, with emphasis on diagnosis, classification, epidemiology, risk factors, microbiology, immunology, systemic complications, anti-infective therapy, reparative treatment, self-care and affordability issues. Learned and unlearned concepts of periodontitis over the past 50 years have shaped our current understanding of the etiology of the disease and of clinical practice.

The relationship between gastroesophageal reflux disease and chronic periodontitis

Background/Aims

The most common cause of chronic periodontitis is poor oral hygiene. Gastroesophageal reflux disease (GERD) enhances the proximal migration of gastric contents and may cause poor oral hygiene. We hypothesized that GERD may increase thse risk of chronic periodontitis and investigated this potential relationship.

Methods

A retrospective cross-sectional study was conducted in outpatients between January 1, 2010, and April 30, 2012. GERD was defined as being present based on at least two of the following criteria: etiologic agent(s), identifiable signs and symptoms, and consistent anatomic alterations. A total of 280 patients with chronic periodontitis and 280 controls were analyzed. Information regarding patient demographics and other potential confounding factors for chronic periodontitis were collected through individual medical records.

Results

GERD was revealed to be independently associated with an increased incidence of chronic periodontitis (odds ratio [OR], 2.883; 95% confidence interval [CI], 1.775 to 4.682). The other three variables of dental caries (OR, 1.531; 95% CI, 1.042 to 2.249), tobacco use (OR, 2.335; 95% CI, 1.461 to 3.730), and history of medication (calcium channel blocker, cyclosporine, or phenytoin) (OR, 2.114; 95% CI, 1.160 to 3.854) were also determined to be independent risk factors.

Conclusions

The present study supported our hypothesis that GERD can be a risk factor for chronic periodontitis.

Adjunctive antibiotics with nonsurgical periodontal therapy improve the clinical outcome of chronic periodontitis in current smokers

SELECTION CRITERIA

A systematic review was performed to identify randomized, controlled, clinical trials designed to study the efficacy of adjunctive antimicrobial therapy with periodontal treatment of chronic periodontitis in smokers. A search was carried out using the databases PubMed (using MeSH terms and free text), EMBASE, SCOPUS, and the Cochrane Central Register of Controlled Clinical Trials, and a manual search of 4 periodontal journals, bibliographies, review articles, and consensus statements. The databases were searched from their earliest records until December 31, 2009. The inclusion criteria of studies were as follows: (1) randomized, controlled clinical studies of ≥6 months study duration; (2) application of a systemic or local adjunctive antimicrobial agent for the treatment of chronic periodontitis in current smokers; (3) measurement of clinical attachment level, probing depth, and bleeding on probing as primary outcomes; (4) no periodontal treatment or use of systemic antibiotics within 6 months of the start of the trial; and (5) publication in an English-language, peer-reviewed journal.

KEY STUDY FACTOR

The key intervention was the use of antibiotics as an adjunct to nonsurgical or surgical periodontal treatment of chronic periodontitis in current smokers. There were no limitations on the type of antibiotics used, regimen, or the route of administration.

MAIN OUTCOME MEASURE

The change in clinical attachment level and probing depth ≥6 months postoperatively following periodontal treatment.

MAIN RESULTS

Five clinical trials met the inclusion criteria and their findings were used in this systematic review. Nine additional studies were excluded: 8 because smokers were not randomized, and 1 because the follow-up was only 3 months. The age of subjects in the included studies ranged from 42 to 52 years, and the sample size ranged from 30 to 181 subjects. Three studies used nonsurgical periodontal therapy (scaling and root planing) (Table 1). The first study used doxycycline 10% gel delivered locally and reported a gain in attachment level 24 months postoperatively. The second study used minocycline 1-mg microspheres delivered locally and reported a reduction in probing depth 9 months postoperatively. In the third study, the experimental group was administered azithromycin 250 mg systemically, and reported a gain in clinical attachment level and a reduction in probing depth 6 months postoperatively. The fourth study used a pocket reduction surgery and adjunctive use of systemic azithromycin 500 mg, and found no significant reduction in probing depth or gain in attachment level 6 months postoperatively. The fifth study used surgical therapy consisting of guided tissue regeneration (GTR) supplemented with local application of metronidazole 25% gel for the treatment of Class II furcation defects. The latter study reported a statistically significant gain in vertical attachment level but no significant change in horizontal attachment level or probing depth during a 12-month follow-up period. The risk of bias in all studies was estimated as high. The authors of the systematic review stated that the reviewed data were inadequate and inconsistent, and therefore meta-analyses were not performed.

CONCLUSIONS

There is no sufficient evidence in the literature to support or refute that adjunctive antibiotic therapy would lead to a significant reduction in probing depth or gain in clinical attachment level when treating periodontitis in smokers.

Low-cost periodontal therapy

Periodontitis is a complex infectious disease that affects low-income individuals disproportionately. Periodontitis is associated with specific bacterial species and herpesviruses, and successful prevention and treatment of the disease is contingent upon effective control of these pathogens. This article presents an efficacious, highly safe, minimally invasive, practical and low-cost periodontal therapy that involves professional and patient-administered mechanical therapy and antimicrobial agents. The major components are scaling for calculus removal, periodontal pocket irrigation with potent antiseptics, and treatment with systemic antibiotics for advanced disease. Povidone-iodine and sodium hypochlorite have all the characteristics for becoming the first-choice antiseptics in the management of periodontal diseases. Both agents show excellent antibacterial and antiviral properties, are readily available throughout the world, have been safely used in periodontal therapy for decades, offer significant benefits for individuals with very limited financial resources, and are well accepted by most dental professionals and patients. Four per cent chlorhexidine applied with a toothbrush to the most posterior part to the tongue dorsum can markedly reduce or eliminate halitosis in most individuals. Systemic antibiotics are used to treat periodontopathic bacteria that are not readily reached by topical therapy, such as pathogens within gingival tissue, within furcation defects, at the base of periodontal pockets, and on the tongue, tonsils and buccal mucosae. Valuable antibiotic therapies are amoxicillin-metronidazole (250 mg of amoxicillin and 250 mg of metronidazole, three times daily for 8 days) for young and middle-aged patients, and ciprofloxacin-metronidazole (500 mg of each, twice daily for 8 days) for elderly patients and for patients in developing countries who frequently harbor enteric rods subgingivally. Scaling to remove dental calculus and the prudent use of inexpensive antimicrobial agents can significantly retard or arrest progressive periodontitis in the great majority of patients.

Effectiveness of systemic amoxicillin/metronidazole as an adjunctive therapy to full-mouth scaling and root planing in the treatment of aggressive periodontitis: a systematic review and meta-analysis

BACKGROUND

The systemic use of combined amoxicillin and metronidazole (AMX/MET) as an adjunctive treatment to full-mouth scaling and root planing (FMSRP) has been proposed for the treatment of generalized aggressive periodontitis; however, its effectiveness and clinical safety remain to be defined. The purpose of the present meta-analysis is to assess the effectiveness of FMSRP + AMX/MET compared to FMSRP alone.

METHODS

An electronic search of eight databases and a hand-search of 10 international dental journals were conducted through September 11, 2011. Gain in clinical attachment level (CAL), reduction in probing depth (PD), secondary outcomes, and adverse events were analyzed. A random-effect model was used to pool the extracted data. The weighted mean difference (MD) with 95% confidence interval (CI) was calculated for continuous outcomes, whereas risk difference (RD) with 95% CI was used for dichotomous data; heterogeneity was assessed with the χ(2)-based Cochran Q test and I(2) statistic. The level of significance was set at P <0.05.

RESULTS

After the selection process, six randomized clinical trials were included. Results of the meta-analysis showed significant CAL gain (MD, 0.42; 95% CI, 0.23 to 0.61; P <0.05) and PD reduction (MD, 0.58; 95% CI, 0.39 to 0.77; P <0.05) in favor of FMSRP + AMX/MET; moreover, no significant RD was found in the occurrence of adverse events (RD, 0.01; 95% CI, -0.02 to 0.04; P >0.05).

CONCLUSION

The findings of the meta-analysis seem to support the effectiveness and the clinical safety of FMSRP + AMX/MET; however, future studies are needed to confirm these results.

Long-term efficacy of subantimicrobial-dose doxycycline as an adjunctive treatment to scaling and root planing: a systematic review and meta-analysis

BACKGROUND

Subantimicrobial-dose doxycycline (SDD) is widely used as an adjunctive treatment to scaling and root planing (SRP), but its long-term effectiveness remains controversial. The purpose of this systematic review was to assess the actual evidence of the effectiveness of SRP + SDD compared to SRP + placebo in the treatment of chronic periodontitis.

METHODS

A literature search of electronic databases was performed for articles published through November 1, 2010. Several dental journals were screened during the manual search, and authors were contacted for missing information. The systematic review and meta-analysis were conducted according to the Quality of Reporting of Meta-Analyses statement and recommendations of the Cochrane Collaboration. The methodologic quality of the studies was determined via a Consolidated Standards of Reporting Trials-based assessment. Clinical attachment levels, probing depths, plaque and gingival indices, and gingival crevicular fluid levels were compared between baseline and the end of follow-up. Data were extracted and pooled using a random-effect model. The weighted mean difference was reported with the 95% confidence interval. Heterogeneity was assessed using the χ(2)-based Q-statistic method and I(2) measurement. P <0.05 was considered statistically significant.

RESULTS

After applying inclusion and exclusion criteria, three randomized placebo-controlled clinical trials were entered into the meta-analysis. These studies had similar treatment designs, SDD dosage regimens (20 mg twice daily for 3 months), and post-treatment follow-up lengths (9 months). Significant differences were observed for all investigated clinical parameters in favor of the SRP + SDD group.

CONCLUSION

The meta-analysis results seemed to support the long-term effectiveness of adjunctive SDD therapy; however, future studies are needed to confirm these findings.