The cost-effectiveness of a new chlorhexidine delivery system in the treatment of adult periodontitis

Comparative Evaluation of Cost-Effectiveness, Clinical and Microbiological Parameters of Systemic Antibiotics Versus Local Drug Delivery in Aggressive Periodontitis

BACKGROUND

Periodontitis is a biofilm-associated inflammatory disease of the periodontium in which microbial component contributes to its initiation that mainly includes chronic periodontitis and aggressive periodontitis (AgP).

AIM

The present study aimed to ascertain a cost-effective treatment approach in AgP with minimal side effects by comparing systemic antibiotics (SA) and local drug delivery (LDD) as an adjunct to scaling and root planning (SRP). Furthermore, the objectives were to analyze its effect on clinical and microbial parameters.

MATERIALS AND METHODS

The participants were randomly divided into two groups A and B with eleven participants each. Group A was administered with Chlosite Gel [LDD] whereas group B with amoxicillin (AMX) 500 mg + metronidazole (MTZ) 400 mg [SA] thrice daily for 14 days. Clinical parameters such as plaque index (PI), gingival index (GI), clinical attachment level (CAL), and pocket probing depth (PPD)] were recorded at baseline and three months postoperatively. Microbiological parameters i.e Aggregatibacter actinomycetemcomitans (Aa) and Porphyromonas gingivalis (Pg) counts were also measured at baseline and after three months.

RESULTS

Statistically significant difference was observed in all clinical parameters i.e. PI, GI, CAL, and PPD after three months follow-up in groups A and B. Reduced bacterial load i.e. Aa and Pg was significant at three months in both the groups. However, on comparing the total expenditure of both the groups, group A ranged from 920-1480 ₹ while in group B it ranged from 330-360 ₹. Hence, lower expenditure in group B (3.7 fold) compared to group A was evident.

CONCLUSIONS

Cost-effective approach recommended in the present study is mainly to promote awareness among periodontal patients in the public and private sectors, who refuse to get dental treatment due to fear of high expenditure. This can be attained by incorporating SA as an alternative to LDD in AgP patients.

Repeated delivery of chlorhexidine chips for the treatment of peri-implantitis: A multicenter, randomized, comparative clinical trial

BACKGROUND

Peri-implantitis is a challenging condition to manage and is frequently treated using non-surgical debridement. The local delivery of antimicrobial agents has demonstrated benefit in mild to moderate cases of peri-implantitis. This study compared the safety and efficacy of chlorhexidine gluconate 2.5 mg chip (CHX chips) as an adjunctive treatment to subgingival debridement in patients afflicted with peri-implantitis.

METHODS

A multicenter, randomized, single-blind, two-arm, parallel Phase-3 study was conducted. Peri-implantitis patients with implant pocket depths (IPD) of 5-8 mm underwent subgingival implant surface debridement followed by repeated bi-weekly supragingival plaque removal and chlorhexidine chips application (ChxC group) for 12 weeks, or similar therapy but without application of ChxC (control group). All patients were followed for 24 weeks. Plaque and gingival indices were measured at every visit whereas IPD, recession, and bleeding on probing were assessed at 8, 12, 16, 24 week.

RESULTS

A total of 290 patients were included: 146 in the ChxC group and 144 in the control. At 24 weeks, a significant reduction in IPD (P = 0.01) was measured in the ChxC group (1.76 ± 1.13 mm) compared with the control group (1.54 ± 1.13 mm). IPD reduction of ≥2 mm was found in 59% and 47.2% of the implants in the ChxC and control groups, respectively (P = 0.03). Changes in gingival recession (0.29 ± 0.68 mm versus 0.15 ± 0.55 mm, P = 0.015) and relative attachment gain (1.47 ± 1.32 mm and 1.39 ± 1.27 mm, P = 0.0017) were significantly larger in the ChxC group. Patients in the ChxC group that were < 65 years exhibited significantly better responses (P < 0.02); likewise, non-smokers had similarly better response (P < 0.02). Both protocols were well tolerated, and no severe treatment-related adverse events were recorded throughout the study.

CONCLUSIONS

Patients with peri-implantitis that were treated with an intensive treatment protocol of bi-weekly supragingival plaque removal and local application of chlorhexidine chips had greater mean IPD reduction and greater percentile of sites with IPD reduction of ≥2 mm as compared with bi-weekly supra-gingival plaque removal.

Sustained-release delivery of antimicrobial drugs for the treatment of periodontal diseases: Fantasy or already reality?

Periodontal diseases are prevalent in humans. Conventional means of combating these diseases involve basic oral hygiene, mostly toothbrushing, use of mouthwashes, and flossing. Supplementary means of treatment, either clinical or pharmaceutical, are often necessary. The use of sustained-release delivery systems, applied locally to the periodontal pocket, seems to be one feasible approach: local sustained-release delivery of antibacterial agents to treat periodontal diseases is conceivable. The use of local (intrapocket) sustained-release delivery systems has numerous clinical, pharmacologic, and toxicologic advantages over conventional treatments for periodontal diseases. Sustained-release technology has been proven to be effective over the last few decades. Films, gels, and fibers are the three main classical intrapocket pharmaceutical delivery systems. Research today is more focused on improving drug delivery, and less on introducing new drugs. New approaches, eg, those making use of nanotechnology, are emerging for local drug-delivery systems. The local sustained-release delivery system concept is innovative and a few products are already commercially available.

A novel injectable chlorhexidine thermosensitive hydrogel for periodontal application: preparation, antibacterial activity and toxicity evaluation

The aim of this paper was to evaluate the application potential of CS-HTCC/GP-0.1%Chx thermosensitive hydrogel which was synthesized using chitosan (CS), quaternized CS, and alpha,beta-glycerophosphate (alpha,beta-GP) loading with 0.1% chlorhexidine (Chx) (w/v) for periodontal treatment. An aqueous solution of CS-HTCC/GP-0.1%Chx was transformed into hydrogel at 6 min when the temperature was increased to 37 degrees C. The scan electron microscopy (SEM) image of the gel was a porous, loose and crosslinked network. In vitro, Chx released over 18 h from the CS-HTCC/GP thermosensitive hydrogel in artificial saliva pH 6.8. Release rate could be controlled through adjustment of alpha,beta-GP or Chx concentration. CS-HTCC/GP-0.1%Chx thermosensitive hydrogel exhibited excellent inhibitory activity against primary periodontal pathogens. CS-HTCC/GP-0.1%Chx thermosensitive hydrogel had no acute toxicity; the maximum tolerated dose in rats was 400 mg/ml. All results indicated that CS-HTCC/GP-0.1%Chx thermosensitive hydrogel is a strong candidate as a local drug delivery system for periodontal treatment.

A Systematic Review on the Effects of the Chlorhexidine Chip When Used as an Adjunct to Scaling and Root Planing in the Treatment of Chronic Periodontitis

BACKGROUND

Several local antimicrobial agents, such as a bioabsorbable chlorhexidine chip, have been developed to enhance the outcome of non-surgical periodontal therapy.

METHODS

Electronic (MEDLINE and Cochrane Oral Health Group Specialized Trials Register) and manual searches were performed to detect studies concerning the use of the chlorhexidine chip as an adjunct to scaling and root planing in the treatment of chronic periodontitis. Only full-text randomized controlled trials published in English up to June 2005 were included.

RESULTS

Five studies were finally selected following independent screening by two reviewers. Due to considerable heterogeneity in study design, a qualitative data analysis was performed. Multicenter studies have indicated significantly higher pocket reductions and clinical attachment gains following a combination of mechanical debridement and repeated chlorhexidine chip administration in comparison to scaling and root planing alone. However, some recent studies failed to confirm the additional value of the chlorhexidine chip. A number of interstudy disparities with respect to methodological quality and study design may account for this lack of accordance.

CONCLUSIONS

The clinical and microbiological data currently available on the chlorhexidine chip are limited and conflicting. More research is needed to elucidate the additional value of the chlorhexidine chip when used as an adjunct to scaling and root planing.

Cost-benefit, cost-effectiveness and cost-utility analyses of periodontitis prevention

OBJECTIVE

The aim of this paper was to determine whether there is evidence that periodontitis prevention is economically justified.

MATERIAL AND METHODS

The characteristics of economic assessments such as cost-benefit, cost-effectiveness and cost-utility analyses were first derived from the literature on health economy. A literature search was conducted using PubMed up to December 2004. Inclusion criteria required that economic analyses be based on scientific principles including a hypothesis, valid comparative groups as well as a cost/benefit, cost/effectiveness and cost/utility assessment.

RESULTS

Only 14 papers were located, which included, in the broadest sense, economic parameters. From these papers, three were systematic reviews, three were randomized controlled studies, four were controlled studies, one was a longitudinal cohort study and three papers were based on statistical modelling. Only one paper reported actual costs for periodontal and dental treatment. Extensive programmes aimed at prevention of periodontal disease in a general population group showed no economic benefit. Adjunctive genetic/and or microbiological testing likewise showed no economic benefit. Economic assessments and real costs are not generally available in the literature. Statistical modelling suggested that non-surgical periodontal procedures are more economical compared with surgical interventions. The use of local delivery devices as an adjunct to Sc/RP showed no economic advantage.

CONCLUSION

It is suggested that economic parameters as well as patient-centred outcomes be included in clinical trials. These data are essential for the appropriate allocation of resources for preventive measures on an individual patient and population base.

Local anti-infective therapy: pharmacological agents. A systematic review

BACKGROUND

It is well recognized that periodontal diseases are bacterial in nature. An essential component of therapy is to eliminate or control these pathogens. This has been traditionally accomplished through mechanical means (scaling and root planing [SRP]), which is time-consuming, difficult, and sometimes ineffective. Over the past 20 years, locally delivered, anti-infective pharmacological agents, most recently employing sustained-release vehicles, have been introduced to achieve this goal.

RATIONALE

This systematic review evaluates literature-based evidence in an effort to determine the efficacy of currently available anti-infective agents, with and without concurrent SRP, in controlling chronic periodontitis.

FOCUSED QUESTION

In patients with chronic periodontitis, what is the effect of local controlled-release anti-infective drug therapy with or without SRP compared to SRP alone on changes in clinical, patient-centered, and adverse outcomes?

SEARCH PROTOCOL

MEDLINE, the Cochrane Central Trials Register, and Web of Science were searched. Hand searches were performed of the Journal of Clinical Periodontology, Journal of Periodontology, and Journal of Periodontal Research. Searches were performed for articles published through April 2002. In addition, investigators contacted editors of the above-mentioned journals and companies sponsoring research on these agents for related unpublished data and studies in progress.

SELECTION CRITERIA

INCLUSION CRITERIA

Studies included randomized controlled clinical trials (RCT), and case-controlled and cohort studies at least 3 months long. Therapeutic interventions had to include 1) SRP alone; 2) local anti-infective drug therapy and SRP; or 3) local anti-infective drug therapy alone. Included studies had to report patient-based mean values and measures of variation for probing depth (PD) and/or clinical attachment levels (CAL) for both test and control groups.

EXCLUSION CRITERIA

Studies were excluded if they: 1) included data from a previously published article; 2) included daily rinsing with chlorhexidine (CHX); or 3) had unclear descriptions of randomization procedures, examiner masking, or concomitant therapies.

DATA COLLECTION AND ANALYSIS

For the meta-analysis, PD and CAL were expressed as summary mean effects with 95% confidence intervals (CI) for the effect, and analyzed using a standardized difference between SRP alone and experimental agent groups. The results were assessed with both fixed-effects and random-effects models. Studies were ranked according to the York system.

MAIN RESULTS

1. Thirty-two studies were included (28 RCT, 2 cohort, and 2 case-control), incorporating a total patient population of 3,705 subjects. 2. Essentially all studies reported substantial reductions in gingival inflammation and bleeding indices, which were similar in both control and experimental groups. 3. A meta-analysis completed on 19 studies that included SRP and local sustained-release agents compared with SRP alone indicated significant adjunctive PD reduction or CAL gain for minocycline (MINO) gel, microencapsulated MINO, CHX chip and doxycycline (DOXY) gel during SRP compared to SRP alone. 4. Use of antimicrobial irrigants or anti-infective sustained-release systems as an adjunct to SRP does not result in significant patient-centered adverse events.

REVIEWERS' CONCLUSIONS

1. In some populations, anti-infective agents in a sustained-release vehicle alone can reduce PD and bleeding on probing (BOP) equivalent to that achieved by SRP alone. 2. No evidence was found for an adjunctive effect on reduction of PD and BOP of therapist-delivered CHX irrigation during SRP compared to SRP alone. 3. Additional RCTs are needed which evaluate the effectiveness of these therapies in all forms of periodontitis. 4. The study protocol for future RCTs should include appropriate statistical analyses and complete data sets to facilitate future evidence-based reviews. 5. Alternative surrogate parameters to PD and CAL need to be identified and validated such as microbial, inflammatory, or tissue-destructive markers that could be used in conjunction with clinical parameters to help determine the patient's response to emerging technologies that target the infectious and/or inflammatory aspects of periodontitis. 6. Future Phase IV clinical trials should be designed that evaluate local anti-infective therapies in conjunction with SRP in a manner consistent with current standards of care and evaluate cost-effectiveness. 7. The use of local anti-infective agents in at-risk patient populations and for the treatment of at-risk disease sites needs to be validated in randomized controlled clinical trials. 8. Several local anti-infective agents combined with SRP appear to provide additional benefits in PD reduction and CAL gain compared to SRP alone. The decision to use local anti-infective adjunctive therapy remains a matter of individual clinical judgment, the phase of treatment, and the patient's status and preferences.

Expert judgement in pharmacoeconomic studies. Guidance and future use

Research in the field of pharmacoeconomics has increased substantially during the past decade. Much of this research has been on the design and analysis of data concerning the relative merits of one drug or device compared with another in terms of costs and effects. Concomitant with these evaluations has been the development of guidelines for the conduct of economic evaluations in several countries. However, despite an increase in research, little attention has been paid to how different study designs may influence the results of a study. The use of expert judgement in decision analytic modelling is one area where design issues may influence the findings of a study. This issue is examined for the case of modified Delphi and Delphi panels. Although the use of expert opinion in modelling studies seems to be widespread, there is little consistent application, understanding or reporting of the techniques used. In particular, the definitions of techniques vary between studies, the criteria for determining when consensus is reached vary, and the reporting of these criteria is absent. Future studies using expert judgement should be more aware of the controversies surrounding the issue and provide more reporting of the techniques used. It is proposed that future validation exercises may assist researchers in determining the most appropriate application of methods.

Controlled and targeted drug delivery strategies towards intraperiodontal pocket diseases

Advances in the understanding of the aetiology, epidemiology, pathogenesis and microbiology of periodontal pocket flora have revolutionized the strategies for the management of intraperiodontal pocket diseases. Intra-pocket, sustained release, drug delivery devices have been shown to be clinically effective in the treatment of periodontal infections. Several degradable and non-degradable devices are under investigation for the delivery of antimicrobial agents into the periodontal pocket including non-biodegradable fibres, films (biodegradable and non-biodegradable), bio-absorbable dental materials, biodegradable gels/ointments, injectables and microcapsules. With the realization that pocket bacteria accumulate as biofilms, studies are now being directed towards eliminating/killing biofilm concentrations rather than their planktonic (fluid phase) counterparts. Intraperiodontal pocket drug delivery has emerged as a novel paradigm for the future research. Similarly, bioadhesive delivery systems are explored that could significantly improve oral therapeutics for periodontal disease and mucosal lesions. A strategy is to target a wide range of molecular mediators of tissue destruction and hence arrest periodontal disease progression. Research into regenerating periodontal structures lost as a result of disease has also shown substantial progress in the last 25 years.