Does adjunctive antimicrobial therapy reduce the perceived need for periodontal surgery?

Adjunctive antimicrobial photodynamic therapy for treating periodontal and peri-implant diseases

BACKGROUND

Periodontitis and peri-implant diseases are chronic inflammatory conditions occurring in the mouth. Left untreated, periodontitis progressively destroys the tooth-supporting apparatus. Peri-implant diseases occur in tissues around dental implants and are characterised by inflammation in the peri-implant mucosa and subsequent progressive loss of supporting bone. Treatment aims to clean the pockets around teeth or dental implants and prevent damage to surrounding soft tissue and bone, including improvement of oral hygiene, risk factor control (e.g. encouraging cessation of smoking) and surgical interventions. The key aspect of standard non-surgical treatment is the removal of the subgingival biofilm using subgingival instrumentation (SI) (also called scaling and root planing). Antimicrobial photodynamic therapy (aPDT) can be used an adjunctive treatment to SI. It uses light energy to kill micro-organisms that have been treated with a light-absorbing photosensitising agent immediately prior to aPDT.

OBJECTIVES

To assess the effects of SI with adjunctive aPDT versus SI alone or with placebo aPDT for periodontitis and peri-implant diseases in adults.

SEARCH METHODS

We searched the Cochrane Oral Health Trials Register, CENTRAL, MEDLINE, Embase, two other databases and two trials registers up to 14 February 2024.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) (both parallel-group and split-mouth design) in participants with a clinical diagnosis of periodontitis, peri-implantitis or peri-implant disease. We compared the adjunctive use of antimicrobial photodynamic therapy (aPDT), in which aPDT was given after subgingival or submucosal instrumentation (SI), versus SI alone or a combination of SI and a placebo aPDT given during the active or supportive phase of therapy.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methodological procedures, and we used GRADE to assess the certainty of the evidence. We prioritised six outcomes and the measure of change from baseline to six months after treatment: probing pocket depth (PPD), bleeding on probing (BOP), clinical attachment level (CAL), gingival recession (REC), pocket closure and adverse effects related to aPDT. We were also interested in change in bone level (for participants with peri-implantitis), and participant satisfaction and quality of life.

MAIN RESULTS

We included 50 RCTs with 1407 participants. Most studies used a split-mouth study design; only 18 studies used a parallel-group design. Studies were small, ranging from 10 participants to 88. Adjunctive aPDT was given in a single session in 39 studies, in multiple sessions (between two and four sessions) in 11 studies, and one study included both single and multiple sessions. SI was given using hand or power-driven instrumentation (or both), and was carried out prior to adjunctive aPDT. Five studies used placebo aPDT in the control group and we combined these in meta-analyses with studies in which SI alone was used. All studies included high or unclear risks of bias, such as selection bias or performance bias of personnel (when SI was carried out by an operator aware of group allocation). We downgraded the certainty of all the evidence owing to these risks of bias, as well as for unexplained statistical inconsistency in the pooled effect estimates or for imprecision when evidence was derived from very few participants and confidence intervals (CI) indicated possible benefit to both intervention and control groups. Adjunctive aPDT versus SI alone during active treatment of periodontitis (44 studies) We are very uncertain whether adjunctive aPDT during active treatment of periodontitis leads to improvement in any clinical outcomes at six months when compared to SI alone: PPD (mean difference (MD) 0.52 mm, 95% CI 0.31 to 0.74; 15 studies, 452 participants), BOP (MD 5.72%, 95% CI 1.62 to 9.81; 5 studies, 171 studies), CAL (MD 0.44 mm, 95% CI 0.24 to 0.64; 13 studies, 414 participants) and REC (MD 0.00, 95% CI -0.16 to 0.16; 4 studies, 95 participants); very low-certainty evidence. Any apparent differences between adjunctive aPDT and SI alone were not judged to be clinically important. Twenty-four studies (639 participants) observed no adverse effects related to aPDT (moderate-certainty evidence). No studies reported pocket closure at six months, participant satisfaction or quality of life. Adjunctive aPDT versus SI alone during supportive treatment of periodontitis (six studies) We were very uncertain whether adjunctive aPDT during supportive treatment of periodontitis leads to improvement in any clinical outcomes at six months when compared to SI alone: PPD (MD -0.04 mm, 95% CI -0.19 to 0.10; 3 studies, 125 participants), BOP (MD 4.98%, 95% CI -2.51 to 12.46; 3 studies, 127 participants), CAL (MD 0.07 mm, 95% CI -0.26 to 0.40; 2 studies, 85 participants) and REC (MD -0.20 mm, 95% CI -0.48 to 0.08; 1 study, 24 participants); very low-certainty evidence. These findings were all imprecise and included no clinically important benefits for aPDT. Three studies (134 participants) reported adverse effects: a single participant developed an abscess, though it is not evident whether this was related to aPDT, and two studies observed no adverse effects related to aPDT (moderate-certainty evidence). No studies reported pocket closure at six months, participant satisfaction or quality of life.

AUTHORS' CONCLUSIONS

Because the certainty of the evidence is very low, we cannot be sure if adjunctive aPDT leads to improved clinical outcomes during the active or supportive treatment of periodontitis; moreover, results suggest that any improvements may be too small to be clinically important. The certainty of this evidence can only be increased by the inclusion of large, well-conducted RCTs that are appropriately analysed to account for change in outcome over time or within-participant split-mouth study designs (or both). We found no studies including people with peri-implantitis, and only one study including people with peri-implant mucositis, but this very small study reported no data at six months, warranting more evidence for adjunctive aPDT in this population group.

Systemic azithromycin versus amoxicillin/metronidazole as an adjunct in the treatment of periodontitis: a systematic review and meta-analysis

BACKGROUND

The use of systemic azithromycin (AZT) and amoxicillin/metronidazole (AMX/MTZ) as adjuncts provided additional clinical and microbiological benefits over subgingival instrumentation alone. However, the superiority of one antibiotic regimen over another has not been proven. Therefore, the aim of this systematic review and meta-analyses was to evaluate the clinical efficacy and safety of subgingival instrumentation (SI) in conjunction with the systemic use of AZT or AMX/MTZ for the treatment of periodontitis from current published literature.

METHODS

Electronic databases were searched to identify randomized controlled trials (RCTs), controlled clinical trials, prospective and retrospective human studies that compared the adjunctive use of systemic AZT to AMX/MTZ with SI in the treatment of periodontitis. The eligibility criteria were defined based on the participant (who had periodontitis), intervention (SI with adjunctive use of systemic AZT), comparison (SI with adjunctive use of systemic AMX/MTZ), outcomes (primary outcome: changes in probing pocket). The risk of bias was assessed using the Cochrane Collaboration's Risk of Bias tool. Data were analysed using a statistical software program.

RESULTS

Five studies with 151 participants with periodontitis were included in the present review. Of these, 74 participants received adjunctive AZT, while the remaining participants received AMX/MTZ as an adjunct to SI. The adjunctive use of AZT and AMX/MTZ had comparable changes in probing pocket depths at 1-3 months with no statistically significant difference (mean difference (MD) 0.01; 95% CI -0.20 to 0.22; P = 0.94). The adjunctive use of AZT had significantly fewer number of residual sites with probing pocket depths of ≥5 mm at 1-3 months compared to the adjunctive use of AMX/MTZ (MD -3.41; 95% CI -4.73 to -2.10; P < 0.0001). The prevalence rates of adverse events among participants who received AZT and AMX/MTZ were 9.80% and 14.8%, respectively. The meta-analysis showed that the difference between the two groups was not statistically significant (risk ratio 0.69; 95% CI 0.28 to 1.72; P = 0.43).

CONCLUSIONS

Within the limitation of this review, there was no superiority between AZT and AMX/MTZ in terms of mean changes in probing pocket depths, clinical attachment level, bleeding on probing at 1-3 months. AZT seem to be associated with less sites with residual probing pocket depths of ≥5 mm at 1-3 months and fewer adverse events compared with AMX/MTZ. © 2023 Australian Dental Association.

Comparative Study of Azithromycin Versus Doxycycline Effect on the Resistin Level in Periodontitis Patients With Type 2 Diabetes: A Randomized Controlled Clinical Trial

AIM

The present study aimed to determine if azithromycin (AZM) and doxycycline therapy, as an adjunct to scaling and root planning (SRP), modulate host response and improve clinical outcomes in periodontitis patients with type 2 diabetes mellitus (T2DM).

PATIENTS AND METHODS

Forty-five periodontal sites in 15 periodontitis patients with T2DM received nonsurgical periodontal therapy (NSPT). In Group I, patients were placebo (not receiving any medication), Group II patients received systemic AZM therapy (AZM 250 mg/day for five days), and Group III patients received doxycycline (20 mg twice per day for three months. The resistin level was collected and measured by enzyme-linked immunosorbent assay (ELISA). Gingival index (GI), probing depth (PD), and clinical attachment level (CAL) were recorded at baseline, one-month, and three-month intervals.

RESULTS

All groups showed improvement in clinical parameters and resistin levels throughout the study. The mean resistin level at three months was the highest in Group I and the lowest in Group III. Patients in Group II showed a larger decrease in mean PD than those in Group I and III. Group III had the highest gain in mean CAL, with an increase of 1.78 mm in attachment.

CONCLUSION

Resistin might be a useful indicator of current disease status. In addition, benefits from adjunctive systemic use of AZM and doxycycline have been administered with non-surgical periodontal therapy.

Evaluating models and assessment techniques for understanding oral biofilm complexity

Oral biofilms are three-dimensional (3D) complex entities initiating dental diseases and have been evaluated extensively in the scientific literature using several biofilm models and assessment techniques. The list of biofilm models and assessment techniques may overwhelm a novice biofilm researcher. This narrative review aims to summarize the existing literature on biofilm models and assessment techniques, providing additional information on selecting an appropriate model and corresponding assessment techniques, which may be useful as a guide to the beginner biofilm investigator and as a refresher to experienced researchers. The review addresses previously established 2D models, outlining their advantages and limitations based on the growth environment, availability of nutrients, and the number of bacterial species, while also exploring novel 3D biofilm models. The growth of biofilms on clinically relevant 3D models, particularly melt electrowritten fibrous scaffolds, is discussed with a specific focus that has not been previously reported. Relevant studies on validated oral microcosm models that have recently gaining prominence are summarized. The review analyses the advantages and limitations of biofilm assessment methods, including colony forming unit culture, crystal violet, 2,3-bis-(2-methoxy-4-nitro-5-sulfophenyl)-2H-tetrazolium-5-carboxanilide inner salt assays, confocal microscopy, fluorescence in situ hybridization, scanning electron microscopy, quantitative polymerase chain reaction, and next-generation sequencing. The use of more complex models with advanced assessment methodologies, subject to the availability of equipment/facilities, may help in developing clinically relevant biofilms and answering appropriate research questions.

Drugs for the Quorum Sensing Inhibition of Oral Biofilm: New Frontiers and Insights in the Treatment of Periodontitis

Chemical molecules are used by microorganisms to communicate with each other. Quorum sensing is the mechanism through which microorganisms regulate their population density and activity with chemical signaling. The inhibition of quorum sensing, called quorum quenching, may disrupt oral biofilm formation, which is the main etiological factor of oral diseases, including periodontitis. Periodontitis is a chronic inflammatory disorder of infectious etiology involving the hard and soft periodontal tissues and which is related to various systemic disorders, including cardiovascular diseases, diabetes and obesity. The employment of adjuvant therapies to traditional scaling and root planing is currently being studied to further reduce the impact of periodontitis. In this sense, using antibiotics and antiseptics involves non-negligible risks, such as antibiotic resistance phenomena and hinders the re-establishment of eubiosis. Different quorum sensing signal molecules have been identified in periodontal pathogenic oral bacteria. In this regard, quorum sensing inhibitors are emerging as some interesting solutions for the management of periodontitis. Therefore, the aim of this review is to summarize the current state of knowledge on the mechanisms of quorum sensing signal molecules produced by oral biofilm and to analyze the potential of quorum sensing inhibitors for the management of periodontitis.

The effect of (-)-epigallocatechin gallate as an adjunct to non-surgical periodontal treatment: a randomized clinical trial

Background

EGCG is proven to be of good effect to relieve periodontal inflammation, but it has not been applied as a local delivery medicine in patients with periodontitis widely. The aim of this clinical trial was to evaluate the adjunctive effect of (-)-epigallocatechin gallate (EGCG) aqueous solution as a coolant during scaling and root planing in the management of chronic periodontitis.

Methods

A double-blind, randomized controlled study was performed on 15 patients with moderate to severe chronic periodontitis. The bilateral maxillary teeth were randomly divided into the test side and the control side on every individual. On the control side, the periodontal therapy was routinely performed. And on the test side, in the process of periodontal therapy, the distilled water in the ultrasonic scaler was replaced with a 5-mg/mL EGCG solution. The probing depth (PPD), clinical attachment level (CAL), bleeding index (BI), gingival index (GI), and plaque index (PI) were recorded at baseline and 6 and 12 weeks after the treatment.

Results

PPD, CAL, BI, GI, and PI generally improved after treatment in both groups. At the sixth week and the twelfth week of review, PPD, CAL, GI, and PI had no statistical difference (p >0.05) between the two groups. At the review of the twelfth week, BI on the test side decreased significantly (p <0.05).

Conclusions

Using EGCG solution as the irrigant instead of water has an additional benefit on the bleeding index at the 12-week review. However, the rest clinical parameters had no additional benefit.

Trial registration

ClinicalTrials.gov ChiCTR2000029831, date of registration: Feb 15, 2020.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-022-06298-6.

The efficacy of systemic antibiotics as an adjunct to surgical treatment of peri-implantitis: a systematic review

BACKGROUND

Microbial biofilm accumulation is the main cause of peri-implantitis. The majority of surgical peri-implantitis treatment protocols suggests adjunctive use of systemic antibiotics to target specific putative bacteria. The aim of this systematic review was to critically evaluate the adjunctive use of systemically administered antibiotics in surgical treatment of peri-implantitis by reviewing previously published systematic reviews and primary studies.

METHODS

A systematic literature search was conducted in four electronic databases (MEDLINE, The Cochrane Library, EMBASE, and Web of Science) for randomised controlled trials, cohort studies, case-control studies, and systematic reviews reporting surgical treatment of peri-implantitis with and without adjunctive systemically administered antibiotic therapy. The included systematic reviews and primary studies were qualitatively assessed using AMSTAR and GRADE, respectively. No restrictions were set for date of publication, journal, or language.

RESULTS

The literature search identified 681 papers. Only seven systematic reviews and two primary studies met the inclusion criteria. Four out of seven included systematic reviews concluded that no evidence exists for use of systemic antibiotics to improve the clinical outcomes in surgical treatment of peri-implantitis. One review did not estimate the level of evidence, one did not clearly state any beneficial effect, whereas one reported a limited adjunctive effect. Further, the two included primary studies did not show a long-term significant benefit of adjunctive use of systemically administrated antibiotics. However, one study reported a short-term adjunctive effect in patients with modified surface implants. Due to heterogeneity in study design, low number of included primary studies, and grade of bias, no meta-analysis was performed.

CONCLUSION

The use of systemically administered antibiotics as an adjunct to surgical interventions of peri-implantitis cannot be justified as a part of a standard treatment protocol. A pervasive problem is the lack of uniform diagnosis criteria for peri-implantitis, deficient information about patient characteristics, absence of high quality long-term randomised controlled trials, and authors' declaration on conflict of interest.

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.

Clinical and microbiological effects of adjunctive photodynamic diode laser therapy in the treatment of chronic periodontitis: A randomized clinical trial

Background. Conventional mechanical debridement alone cannot eliminate bacteria and their products from periodontal pockets. Adjunctive therapies improve tissue healing through detoxification and bactericidal effects. Photodynamic therapy (PDT) is a non-invasive treatment procedure that involves the use of a dye as a photosensitizer to attach to the target cell and be activated by a photon of an appropriate wavelength. This study aimed to assess the effectiveness of PDT in treating periodontitis as an adjunct to scaling and root planing.

Methods. Fifteen subjects with chronic periodontitis were treated randomly with scaling and root planing (SRP), followed by a single PDT (test) or SRP (control) episode alone. Full-mouth plaque index (PI), sulcus bleeding index (SBI), probing depth (PD), and clinical attachment level (CAL) were assessed at baseline and 1-month and 3-month intervals. Microbiological evaluation of Porphyromonas gingivalis (Pg) in subgingival plaque samples was performed using a commercially available real-time polymerase chain reaction.

Results. The results revealed a significant difference in PI, SBI, PD, CAL, and microbiological parameters between the groups one and three months after treatment.

Conclusion. A combination of PDT and SRP gave rise to a significant improvement in clinical and microbiological parameters in patients with chronic periodontitis.

Local delivery therapies as adjuvants to non-surgical periodontal treatment of periodontitis grade C: a systematic review

OBJECTIVES

The aim of this article was to perform a systematic review on the effectiveness of local adjuvant therapies in the treatment of aggressive periodontitis (AgP), now reported as periodontitis grade C.

MATERIALS AND METHODS

The authors selected randomized clinical trials of AgP patients who received local therapy as adjuvants to non-surgical periodontal with a duration of at least 90 days. Seven databases were searched up to January 2020. The gain in clinical attachment level (CAL) and reduction of probing depth (PD) were the outcomes of interest.

RESULTS

Of the 3583 studies found, only five articles were included in the qualitative analysis. Among the substances analyzed, only 1.2 mg of simvastatin gel (SMV) (1.2 mg/0.1 ml), 1% of alendronate gel (ALN) (10 mg/ml), and 25% metronidazole gel (MTZ) (Elyzol^@) showed a significant decrease in the probing depth when compared with their respective control groups. The gain CAL was shown using 1.2 mg SMV gel (1.2 mg/0.1 ml) and 1% ALN gel (10 mg/ml).

CONCLUSION

Although 1.2 mg SMV gel (1.2 mg/0.1 ml), 1% ALN gel (10 mg/ml), and 25% MTZ gel (Elyzol) have shown better results, local therapies adjuvant to SRP the data found were limited. Future clinical studies with appreciable methodological quality should be conducted.

CLINICAL RELEVANCE

Despite some benefits of local delivery therapy, up to now, it has not been possible to prove the efficacy of local therapy as an adjunct to standard treatment of AgP (periodontitis grade C).

Second Generation of Zafirlukast Derivatives with Improved Activity against the Oral Pathogen Porphyromonas gingivalis

Porphyromonas gingivalis is a Gram-negative anaerobic pathogen that can trigger oral dysbiosis as an early event in the pathogenesis of periodontal disease. The FDA-approved drug zafirlukast (ZAF) was recently shown to display antibacterial activity against P. gingivalis. Here, 15 novel ZAF derivatives were synthesized and evaluated for their antibacterial activity against P. gingivalis and for their cytotoxic effects. Most derivatives displayed superior antibacterial activity against P. gingivalis compared to ZAF and its first generation derivatives along with little to no growth inhibition of other oral bacterial species. The most active compounds displayed bactericidal activity against P. gingivalis and less cytotoxicity than ZAF. The superior and selective antibacterial activity of ZAF derivatives against P. gingivalis along with an increased safety profile compared to ZAF suggest these new compounds, especially 14b and 14e, show promise as antibacterials for future studies aimed to test their potential for preventing/treating P. gingivalis-induced periodontal disease.

Three periodontitis phenotypes: Bone loss patterns, antibiotic-surgical treatment and the new classification

AIM

To compare three periodontitis clusters (A, B and C) for alveolar bone loss (ABL) patterns, antibiotic prescriptions and surgeries and to relate them to the new classification of periodontitis.

MATERIALS AND METHODS

ABL patterns, prescription of systemic antibiotics and the number of surgeries were retrieved for all patients (n = 353) in the clusters. Comparisons and possible predictors for antibiotics were assessed, and results also evaluated in relation to the new classification.

RESULTS

Cluster A is characterized by angular defects often affecting the first molars and localized stage III/IV grade C periodontitis. Cluster B contains mainly localized or generalized stage III/IV, grade C patients. Cluster C contains mainly patients with generalized stage III/IV grade C periodontitis. Patients in cluster A received significantly more antibiotics compared to B and C (78% vs. 23% and 17%); the predictors for antibiotic prescription were young age and localized ABL. No differences in numbers of periodontal surgeries were observed between clusters (A = 1.0 ± 1.4, B = 1.3 ± 1.4 and C = 1.3 ± 1.5).

CONCLUSIONS

Within stage III/IV grade C periodontitis, we could detect three clusters of patients. The distinct localized ABL pattern and younger age in cluster A presumably prompted clinicians to prescribe antibiotics.

Influence of adjunctive azithromycin on microbiological and clinical outcomes in periodontitis patients: 6-month results of randomized controlled clinical trial

BACKGROUND

Our aim was to determine if azithromycin therapy, as an adjunct to scaling and root planing (SRP), decreases the number of pathobiontic subgingival plaque species and sites demonstrating pocket depth (PD) ≥ 5 mm and bleeding on probing (BOP) 6 months post-treatment.

METHODS

In a double-blind randomized parallel-arm placebo-controlled trial, 40 patients received nonsurgical periodontal treatment in two sessions within 7 days. Patients then received systemic antibiotic therapy (n = 20, azithromycin 500 mg/day for 3 days) or placebo (n = 20). Pooled microbiologic samples were taken before and 6 months after therapy and analysed by established culture methods. The primary outcome variable was the number of sites with PD ≥ 5 mm and BOP at the 6-month re-evaluation. Using multivariate multilevel logistic regression, the effects of gender, age, antibiotic therapy, presence of P. gingivalis or A. actinomycetemcomitans, smoking, tooth being a molar and interdental location were evaluated.

RESULTS

The number of sites with PD ≥ 5 mm and BOP after 6 months was similar in the test (Me = 4, IQR = 0-11) and control (Me = 5, IQR = 1-22) group. Adjunctive azithromycin treatment, compared to SRP alone, resulted in more frequent eradication of A. actinomycetemcomitans (p = 0.013) and C. rectus (p = 0.029), decreased proportion (p = 0.006) and total counts (p = 0.003) of P. gingivalis, and decreased proportion of C. rectus (p = 0.012). Both groups showed substantial but equivalent improvements in periodontal parameters, with no intergroups differences at initially shallow or deep sites. The logistic regression showed a lower odds ratio for healing of diseased sites on molars (OR = 0.51; p <  0,001).

CONCLUSION

Despite significant changes in numbers of A. actinomycetemcomitans, P. gingivalis and C. rectus, patients with periodontitis do not benefit from adjunctive systemic azithromycin in terms of number of persisting sites with PD ≥ 5 mm and BOP.

TRIAL REGISTRATION

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

Effects of timing of adjunctive systemic antibiotics on the clinical outcome of periodontal therapy: A systematic review

Background

Many systematic reviews and meta-analysis have indicated beneficial effects of adjunctive systemic antibiotics in periodontal therapy in specific situations. However, some essential issues such as the ideal time of their administration during periodontal therapy remain unanswered. This systematic review aimed to determine at which phase of periodontal treatment would adjunctive systemic antibiotics lead to the best clinical outcomes, during the active phase or in the reevaluation phase.

Material and Methods

Searches in the databases Medline, Scopus and Cochrane Library were conducted. The randomized clinical trials and retrospective cohort studies comparing the clinical benefits of adjunctive systemic antibiotic administration in the active phase of periodontal treatment versus their administration in the reevaluation phase were included. The primary outcomes assessed were differences in clinical changes in periodontal pocket depth and clinical attachment loss at all post-treatment phases.

Results

Of the 6209 records identified, two randomized clinical trials and two retrospective cohort studies were eligible according to inclusion criteria. Two studies suggested there were greater clinical benefits when systemic antibiotics were prescribed during the active phase of periodontal therapy than in the reevaluation phase while two other studies showed no significant difference in clinical outcomes at 6 months between these two different timing of administration.

Conclusions

The evidence available and evaluated in this systematic review is of heterogeneous quality and limited by the restricted number of studies and their dissimilarities in their study design and outcome reporting. Despite insufficient evidence to determine the ideal time to the adjunctive systemic antibiotic administration in the periodontal therapy, it seems that prescription of systemic antibiotic at the active phase of periodontal therapy leads to better clinical outcomes.

Key words:Active phase; periodontal therapy, periodontitis, reevaluation, systemic antibiotics, timing.

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.

The impact of predatory bacteria on experimental periodontitis

BACKGROUND

This study evaluated the effects of topical administration of Bdellovibrio bacteriovorus HD100 on experimental periodontitis (EP) in rats.

METHODS

Thirty-two rats were divided into groups C (control), EP, C-HD100, and EP-HD100. At day 0, animals of groups EP and EP-HD100 received cotton ligatures around mandibular first molars (MFM). In groups C-HD100 and EP-HD100, 1 mL of suspensions containing B. bacteriovorus HD100 was topically administered in the subgingival region of MFMs at days 0, 3, and 7. Animals were euthanized at day 14. Gingival tissue, hemimandibles, and oral biofilm were collected. Data were statistically analyzed.

RESULTS

Group EP-HD100 presented greater bone volume and lower connective tissue attachment loss (CTAL) than group EP (P < 0.05). Group EP-HD100 presented greater proportions of Actinomyces and Streptococcus-like species and lower proportions of Prevotella intermedia, Peptostreptococcus micros, Fusobacterium nucleatum, Fusobacterium polymorphum, Eikenella corrodens, Eubacterium nodatum, Campylobacter gracilis, Capnocytophaga sputigena, and Veillonella parvula-like species than group EP. Group EP-HD100 presented greater levels of osteoprotegerin and gene expression of interleukin (IL)-17, IL-10, and forkhead box P3 than group EP (P < 0.05).

CONCLUSION

Topical use of B. bacteriovorus HD100 promotes a protective effect against alveolar bone loss and CTAL in rats with EP.

Prescribing trends of systemic antibiotics by periodontists in Australia

BACKGROUND

Antibiotics are a common systemic pharmaceutical therapy in periodontal conditions for dental practitioners as well as specialists. However, there is limited information about prescribing patterns amongst the periodontists within Australia. The objective of this study is to examine current patterns and perceptions in prescribing systemic antibiotics for the treatment of periodontal and peri-implant diseases.

METHODS

An online questionnaire was disseminated to Australian practicing members of the Australia and New Zealand Academy of Periodontists (ANZAP) to determine their antibiotic prescribing patterns for different periodontal conditions. Indications that were analyzed included: chronic periodontitis, plaque-induced gingivitis, aggressive periodontitis, acute gingival and periodontal conditions, conditions associated with implants and implant placement, periodontal regeneration, and mucogingival surgery.

RESULTS

Out of the 50 members that participated in the study, 38 completed the questionnaire. Systemic antibiotics prescription patterns varied markedly for different periodontal or peri-implant diseases among respondents. 79% reported prescription of systemic antibiotics in the treatment of chronic periodontitis whereas 52.6%, 55.3%, 18.4% of the respondents did so for periodontal regeneration procedures, implant placement surgery, and mucogingival surgery, respectively. Azithromycin, the combination of Amoxicillin and Metronidazole, and Amoxicillin were the three most commonly prescribed systemic antibiotics.

CONCLUSION

Based on the results of this survey, systemic antibiotics are widely used by the group of periodontists surveyed in this study in Australia with varying rates and patterns for different periodontal and peri-implant conditions. The current study highlights the need for recommendations and guidelines in the prescription of antibiotics for periodontal and peri-implant conditions.

Comparison of clinical effectiveness of single and multiple applications of 1% chlorhexidine varnish (Cervitec Plus) along with scaling and root planing in patients with chronic periodontitis

Background:

Local drug delivery is most commonly used as an adjunct to scaling and root planing (SRP) for the treatment of periodontal disease. Varied success rates have been documented for various vehicles used for intrasite delivery of active therapeutic agents. Recently, varnishes acting as a reservoir of chlorhexidine have shown potential for the management of chronic periodontitis patients. The aim of the present investigation was a comparative evaluation of the clinical effectiveness of single and multiple applications of 1% chlorhexidine and thymol varnish (Cervitec Plus) along with SRP in patients with chronic periodontitis.

Materials and Methods:

The present study included 30 patients with chronic periodontitis divided into three groups based on the number of subgingival applications of chlorhexidine varnish single application (Group A), two applications at a week's interval (Group B), and three applications with 7-day interval in between two applications (Group C). Clinical parameters, namely plaque index (PI), sulcus bleeding index, probing pocket depth (PPD), and relative attachment level (RAL) were recorded at baseline, 1 month and 3 months in all three groups to compare the clinical efficacy.

Results:

A statistically significant reduction was observed in PI, sulcus bleeding index, PPD, and RAL at 1 and 3 months in all the three groups. Greater (though statistically nonsignificant) improvements were observed in Groups B and C.

Conclusion:

Within limitations of the study, it can be concluded that multiple applications of 1% chlorhexidine and thymol varnish (Cervitec Plus) have an added benefit over the single application in the treatment of chronic periodontitis.

Optimal design of thiostrepton-derived thiopeptide antibiotics and their potential application against oral pathogens

A new fluorinated thiostrepton-type thiopeptide antibiotic was designed and biosynthesized by using a biological approach with synthetic advantages. Related bioassays indicated that thiostrepton and its derivatives hold potential in oral pathogen treatment.

The effect of green tea as an adjunct to scaling and root planing in non-surgical periodontitis therapy: a systematic review

OBJECTIVE

To provide a systematic overview on the efficacy of green tea catechin as an adjunct to scaling and root planing (SRP) in terms of probing pocket depth (PPD).

MATERIALS AND METHODS

A systematic literature search was performed using electronic databases in PubMed, Scopus, Medline, Cochrane, CINAHL, and Web of Science on randomized clinical trials up to January 2017. The research question was posed in accordance with PRISMA guidelines.

RESULTS

The search provided 234 studies. After analyzing the full texts, five studies were included, with four studies qualifying for meta-analysis. Mean PPD reduction was significantly higher (α = 0.05) when green tea catechin was used as an adjunct to SRP (test group) than with SRP alone (control group). The difference in the reduction was 0.74 mm [0.35-1.13; 95% CI].

CONCLUSION

The local application of green tea catechin as an adjunct to SRP may result in a beneficial reduction in PPD. Due to the highly heterogeneous data and some risk of bias, however, this data still needs to be interpreted with caution.

CLINICAL RELEVANCE

The finding suggests that green tea catechin may be a topical adjunct to SRP without negative side effects.

Comparing the Antimicrobial In Vitro Efficacy of Amoxicillin/Metronidazole against Azithromycin-A Systematic Review

On account of its proven clinical efficacy, the combination of systemically administered amoxicillin and metronidazole is frequently adjuncted to non-operative periodontal therapy and well documented. Potential drawbacks of this regimen, e.g., side effects and problems with the compliance, led to an ongoing search for alternatives. Azithromycin, an antibiotic extensively used in general medicine, has recently found its niche in periodontal therapy as well. This systematic review aimed to analyze the in vitro antimicrobial efficacy of amoxicillin plus metronidazole versus azithromycin. For this purpose, a systematic literature search was performed, and studies published up to 29 March 2018 referenced in Medline, Embase, Cochrane, and Biosis were independently screened by two authors. An additional hand search was performed and studies focusing on the evaluation of in vitro antimicrobial efficacy of amoxicillin + metronidazole or azithromycin on bacteria from the subgingival biofilm were included. English and German language research reports were considered. From 71 identified articles, only three articles were eligible for inclusion. These studies showed heterogeneity in terms of analytical methods and strains explored. However, all studies used multispecies biofilm models for analysis of the antimicrobial activity. Unanimously, studies reported on more pronounced antimicrobial effects when applying the combination of amoxicillin + metronidazole, compared to azithromycin. Based on the few studies available, the combination of amoxicillin + metronidazole seemed to display higher antimicrobial efficacy in vitro than azithromycin.

Nonsurgical and surgical treatment of periodontitis: how many options for one disease?

Treatment of periodontitis aims at preventing further disease progression with the intentions to reduce the risk of tooth loss, minimize symptoms and perception of the disease, possibly restore lost periodontal tissue and provide information on maintaining a healthy periodontium. Therapeutic intervention includes introduction of techniques to change behavior, such as: individually tailored oral-hygiene instructions; a smoking-cessation program; dietary adjustment; subgingival instrumentation to remove plaque and calculus; local and systemic pharmacotherapy; and various types of surgery. No single treatment option has shown superiority, and virtually all types of mechanical periodontal treatment benefit from adjunctive antimicrobial chemotherapy. Periodontal treatment, because of the chronic nature of periodontitis, is a lifelong commitment to intricate oral-hygiene techniques, which, when properly implemented, will minimize the risk of disease initiation and progression.

Randomized clinical trial of the effects of azithromycin use in the treatment of peri-implantitis

BACKGROUND

The aim of this clinical trial was to establish a proof of concept that the adjunctive use of systemic azithromycin (AZM) in conjunction with mechanical debridement has an increased benefit in reducing soft tissue inflammation in the treatment of peri-implantitis.

METHODS

In a randomized, double-blind, clinical trial, the treatment group (nine patients) received AZM as well as mechanical debridement in a single course of treatment, whereas the control group (eight patients) received a placebo and mechanical debridement. The primary outcome variables studied were bleeding on probing, suppuration, pocket probing depth and gingival recession. The secondary variables studied were gingival index, plaque index, microbiological and interleukin-1β status. The observation period was 6 months.

RESULTS

Over the 6 months' observation period, the treatment patients showed a consistently greater reduction of gingival inflammation and an improvement in soft tissue healing than the control patients.

CONCLUSIONS

The adjunctive use of a single course of systemic azithromycin can assist in the control of peri-implant mucositis in the treatment of peri-implantitis.

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.

Kava-241 reduced periodontal destruction in a collagen antibody primed Porphyromonas gingivalis model of periodontitis

AIM

The aim of this study was to evaluate the effect of Kava-241, an optimized Piper methysticum Kava compound, on periodontal destruction in a collagen antibody primed oral gavage model of periodontitis.

METHODS

Experimental periodontitis was induced by oral gavage of Porphyromonas gingivalis (P. gingivalis) + type II collagen antibody (AB) in mice during 15 days. Mice were treated with Kava-241 concomitantly or prior to P. gingivalis gavage and compared to untreated mice. Comprehensive histomorphometric analyses were performed.

RESULTS

Oral gavage with P. gingivalis induced mild epithelial down-growth and alveolar bone loss, while oral gavage with additional AB priming had greater tissular destruction in comparison with gavage alone (p < .05). Kava-241 treatment significantly (p < .05) reduced epithelial down-growth (72%) and alveolar bone loss (36%) in P. gingivalis+AB group. This Kava-241 effect was associated to a reduction in inflammatory cell counts within soft tissues and an increase in fibroblasts (p < .05).

CONCLUSION

Priming with type II collagen antibody with oral gavage is a fast and reproducible model of periodontal destruction adequate for the evaluation of novel therapeutics. The effect of Kava-241 shows promise in the prevention and treatment of inflammation and alveolar bone loss associated with periodontitis. Further experiments are required to determine molecular pathways targeted by this therapeutic agent.

The effects of periodontal treatment on pregnancy outcomes

BACKGROUND

Preterm infants are at greater risk than term infants for physical and developmental disorders. Morbidity and mortality increases as gestational age at delivery decreases. Observational studies indicate an association between poor periodontal health and risk for preterm birth or low birthweight, making periodontitis a potentially modifiable risk factor for prematurity.

AIM

To identify randomized controlled trials (RCTs) published between January 2011 and July 2012 and discuss all published RCTs testing whether periodontal therapy reduces rates of preterm birth and low birthweight.

METHODS

Search of databases including PubMed, ISI Web of Science and Cochrane Library.

RESULTS

The single RCT identified showed no significant effect of periodontal treatment on birth outcomes.

DISCUSSION

All published trials included non-surgical periodontal therapy; only two included systemic antimicrobials as part of test therapy. The trials varied substantially in terms of sample size, obstetric histories of subjects, study preterm birth rates and the periodontal treatment response. The largest trials - also judged to be high-quality and at low risk of bias - have yielded consistent results, and indicate that treatment does not alter rates of adverse pregnancy outcomes.

CONCLUSION

Non-surgical periodontal therapy, scaling and root planing, does not improve birth outcomes in pregnant women with periodontitis.

Effectiveness of Subgingival Irrigation as an Adjunct to Scaling and Root Planing in the Treatment of Chronic Periodontitis: A Systematic Review

AIM

Subgingival applications of various chemotherapeutic agents have been used as an adjunct to nonsurgical periodontal treatment and preventive periodontal therapy. Their use in regular clinical practice, however, is less, perhaps due to concerns about clinical success or probably due to a lack of knowledge of their effectiveness or cost. The aim of this systematic review is to obtain overall quantitative estimate of effectiveness of subgingival irrigation (SI) in the treatment of chronic periodontitis.

MATERIALS AND METHODS

A literature search of electronic database was performed for articles published through December 31, 2014, followed by manual search of dental journals. Randomized controlled trails (RCTs) assessing the effect of SI as an adjunct to scaling and root planing (SRP) in the treatment of chronic periodontitis evaluated by changes in the clinical and microbiological outcomes were included.

RESULTS

This literature search yielded only two randomized, placebo-controlled studies that evaluated the efficacy of SI as an adjunct to SRP in patients with chronic periodontitis. The studies were methodologically not perfect (in terms of mediocre quality) with a risk of bias to come to any final conclusions to be reached. These studies didn't clearly mention about randomization, allocation concealment, blinding, dosage and formulation of irrigants, severity of periodontal disease, patient-centered outcomes and results data.

CONCLUSION

Due to insufficient evidence supporting the efficacy of SI as an adjunct to SRP in treating chronic periodontitis, more rigorous scientific research is required to assess the efficacy of SI as an adjunct to SRP in the treatment of periodontal diseases.

Should Antibiotics Be Prescribed to Treat Chronic Periodontitis?

Although scaling and root planing is a cost-effective approach for initial treatment of chronic periodontitis, it fails to eliminate subgingival pathogens and halt progressive attachment loss in some patients. Adjunctive use of systemic antibiotics immediately after completion of scaling and root planing can enhance the degree of clinical attachment gain and probing depth reduction provided by nonsurgical periodontal treatment. This article discusses the rationale for prescribing adjunctive antibiotics, reviews the evidence for their effectiveness, and outlines practical issues that should be considered before prescribing antibiotics to treat chronic periodontitis.

Systemic moxifloxacin vs amoxicillin/metronidazole adjunct to non-surgical treatment in generalized aggressive periodontitis

Background

The objective of this randomized clinical study was to evaluate the effect of systemic administration of moxifloxacin compared to amoxicillin and metronidazole, combined with non-surgical treatment in patients with generalized aggressive periodontitis (GAgP) in a 6-month follow-up.

Material and Methods

A total of 39 systemically healthy patients with GAgP were evaluated in this randomized clinical trial. Periodontal parameters were recorded at the baseline during the 1st, 3rd and 6th month. Patients received either 400 mg of moxifloxacin per os once daily or 500 mg of metronidazole and 500 mg amoxicillin per os three times daily for 7 days consecutively.

Results

No significant differences between groups were found in any parameters at the baseline. Both groups led to a statistically significant decrease in all clinical periodontal parameters compared to the baseline (PI, p<0.001 and GI, PD, BOP, CAL, p<0.01). There were no differences between the 1st and 3rd months or the 3rd and 6th months for clinical parameters in the groups. Also, no intergroup difference was observed in any parameters at any time, except the gingival index at 6th months.

Conclusions

Systemic administration of moxifloxacin as an adjunct to non-surgical treatment significantly improves clinical outcomes and provides comparable clinical improvement with less adverse events to that of combination of amoxicillin and metronidazole in the treatment of GAgP.

Key words: Aggressive periodontitis, amoxicillin, metronidazole, moxifloxacin, nonsurgical periodontal debridement.

Non-surgical periodontal therapy supplemented with systemically administered azithromycin: a systematic review of RCTs

BACKGROUND

Azithromycin may be an alternative adjunctive systemic antibiotic in non-surgical periodontal therapy.

OBJECTIVE

This study aims to identify randomized controlled trials evaluating non-surgical periodontal treatment of chronic and/or aggressive periodontitis supplemented with systemically administered azithromycin.

MATERIALS AND METHODS

A systematic literature search was performed for publications published by 31 March 2014 using electronic databases and hand search. Randomized controlled trials published in English or German language, with a follow-up ≥6 months were included. From 231 titles identified, nine publications were eligible for inclusion.

RESULTS

Among the studies included, showing some risk of bias, seven reported on patients with chronic periodontitis and two with aggressive periodontitis. Minor adverse events were described in five studies. A synthesis of results using a vote counting method was applied. Significant (p < 0.05) beneficial effects of azithromycin were shown in six studies for probing depth changes and in five studies for clinical attachment level changes.

CONCLUSION

In contrast to aggressive periodontitis patients, data from this analysis indicate a potential benefit of systemic azithromycin as adjunctive to non-surgical periodontal therapy in chronic periodontitis patients.

CLINICAL RELEVANCE

When contraindications for the standard antibiotics are present, azithromycin (AZM) may be considered as alternative systemically administered antibiotic drug in selected cases of chronic periodontitis.

An estimate of pocket closure and avoided needs of surgery after scaling and root planing with systemic antibiotics: a systematic review

BACKGROUND

Relevant benefits of adjunctive medication of antibiotica after conventional root surface debridement in terms of enhanced pocket depth (PD) reduction have been shown. However, means and standard deviations of enhanced reductions are difficult to translate into clinical relevant treatment outcomes such as pocket resolution or avoidance of additional surgical interventions. Accordingly, the aim of this systematic review was to calculate odds ratios for relevant cut-off values of PD after mechanical periodontal treatment with and without antibiotics, specifically the combination of amoxicilline and metronidazol, from published studies. As clinical relevant cut-off values "pocket closure" for PD ≤ 3mm and "avoidance of surgical intervention" for PD ≤ 5 mm were determined.

METHODS

The databases PubMed, Embase and Central were searched for randomized clinical studies assessing the beneficial effect of the combination of amoxicillin and metronidazole after non-surgical mechanical debridement. Titles, abstracts and finally full texts were scrutinized for possible inclusion by two independent investigators. Quality and heterogeneity of the studies were assessed and the study designs were examined. From published means and standard deviations for PD after therapy, odds ratios for the clinically relevant cut-off values were calculated using a specific statistical approach.

RESULTS

Meta-analyses were performed for the time points 3 and 6 month after mechanical therapy. Generally, a pronounced chance for pocket closure from 3 to 6 months of healing was shown. The administration of antibiotics resulted in a 3.55 and 4.43 fold higher probability of pocket closure after 3 and 6 months as compared to mechanical therapy alone. However, as the estimated risk for residual pockets > 5 mm was 0 for both groups, no odds ratio could be calculated for persistent needs for surgery. Generally, studies showed a moderate to high quality and large heterogeneity regarding treatment protocol, dose of antibiotic medication and maintenance.

CONCLUSION

With the performed statistical approach, a clear benefit in terms of an enhanced chance for pocket closure by co-administration of the combination of amoxicillin and metronidazole as an adjunct to non-surgical mechanical periodontal therapy has been shown. However, data calculation failed to show a benefit regarding the possible avoidance of surgical interventions.

Antibiotics in the treatment of periodontal disease: a guide for the general dental practitioner

The objective of the present paper is to discuss the appropriate use of systemic and local adjunctive antibiotics/antimicrobials in the management of periodontal diseases using a number of case studies to illustrate an evidence-based approach to treatment.

Antimicrobial prophylaxis in dentistry

Use of antibiotics both in humans and animals runs along with effects that can contribute to the spread of antibiotic resistance. Although several available guidelines for antibiotic treatment have been published to date, clinical practice in dentistry and particularly in oral surgery is not free from controversies regarding antibiotic prophylaxis. Antibiotic coverage to prevent infectious endocarditis, joint prostheses infections or local infections requires a careful evaluation of the patient condition, associated risks and other aspects that could influence the decision. It is of great relevancy for oral surgeons and for dentists in general to know exactly what they are up against. Here we review the literature regarding prophylactic use of antimicrobials in dentistry.

Lessons learned and unlearned in periodontal microbiology

Periodontal diseases are initiated by bacterial species living in polymicrobial biofilms at or below the gingival margin and progress largely as a result of the inflammation elicited by specific subgingival species. In the past few decades, efforts to understand the periodontal microbiota have led to an exponential increase in information about biofilms associated with periodontal health and disease. In fact, the oral microbiota is one of the best-characterized microbiomes that colonize the human body. Despite this increased knowledge, one has to ask if our fundamental concepts of the etiology and pathogenesis of periodontal diseases have really changed. In this article we will review how our comprehension of the structure and function of the subgingival microbiota has evolved over the years in search of lessons learned and unlearned in periodontal microbiology. More specifically, this review focuses on: (i) how the data obtained through molecular techniques have impacted our knowledge of the etiology of periodontal infections; (ii) the potential role of viruses in the etiopathogenesis of periodontal diseases; (iii) how concepts of microbial ecology have expanded our understanding of host-microbe interactions that might lead to periodontal diseases; (iv) the role of inflammation in the pathogenesis of periodontal diseases; and (v) the impact of these evolving concepts on therapeutic and preventive strategies to periodontal infections. We will conclude by reviewing how novel systems-biology approaches promise to unravel new details of the pathogenesis of periodontal diseases and hopefully lead to a better understanding of their mechanisms.

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.

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.