Clinical Efficacy of Single Application Local Drug Delivery and Adjunctive Agents in Nonsurgical Periodontal Therapy: A Systematic Review and Network Meta-Analysis

Knowledge, attitudes and practices among patients with periodontal disease toward disease management

Introduction

Periodontal disease is a common chronic inflammatory condition that affects oral health and carries broader public health implications. This study aimed to assess the levels of knowledge, attitudes and practices (KAP) among patients with periodontal disease toward disease management.

Methods

This cross-sectional web-based study was conducted between March 2022 and March 2023. A self-administered questionnaire was designed to evaluate KAP toward disease management.

Results

A total of 514 questionnaires were collected. Among the patients, 313 (60.89%) of them were female, 309 (60.12%) resided in urban areas and 130 (25.29%) reported having severe periodontal disease. The mean scores of knowledge, attitudes and practices were 3.05 ± 2.03 (possible range: 0-8), 18.71 ± 3.64 (possible range: 6-30), and 14.85 ± 3.63 (possible range: 5-25), respectively. The knowledge item with highest correctness rate was the link between periodontal disease and systemic health (60.70%), while the lowest correctness rate was seen for understanding disease classification (36.96%). Pearson's analysis revealed positive correlations between knowledge and attitude (r = 0.31, p < 0.001), knowledge and practices (r = 0.23, p < 0.001) attitudes, as well as attitudes and practices (r = 0.17, p < 0.001). Multivariate logistic regression analysis showed that knowledge (OR = 1.30, 95% CI: 1.14-1.49, p < 0.001), age ≥ 33 years old (OR = 0.33, 95% CI: 0.18-0.62, p = 0.001), housewife/househusband (OR = 0.41, 95% CI: 0.17-0.95, p = 0.037) and student (OR = 0.43, 95% CI: 0.20-0.92, p = 0.029) were independently associated with practices.

Conclusion

Patients with periodontal disease had insufficient knowledge, negative attitudes, and passive practices toward disease management. Further efforts could be directed toward enhancing patient education on periodontal disease to improve knowledge, thereby positively influencing attitudes and disease management practices.

Supra and subgingival application of antiseptics or antibiotics during periodontal therapy

Periodontal diseases (gingivitis and periodontitis) are characterized by inflammatory processes which arise as a result of disruption of the balance in the oral ecosystem. According to the current S3 level clinical practice guidelines, therapy of patients with periodontitis involves a stepwise approach that includes the control of the patient's risk factors and the debridement of supra and subgingival biofilm. This debridement can be performed with or without the use of some adjuvant therapies, including physical or chemical agents, host modulating agents, subgingivally locally delivered antimicrobials, or systemic antimicrobials. Therefore, the main aim of this article is to review in a narrative manner the existing literature regarding the adjuvant application of local agents, either subgingivally delivered antibiotics and antiseptics or supragingivally applied rinses and dentifrices, during the different steps in periodontal therapy performed in Europe.

Methodological quality of network meta-analysis in dentistry: a meta-research

This meta-research aimed to provide an overview of the methodological quality and risk of bias of network meta-analyses (NMA) in dentistry. Searches for NMA of randomized clinical trials with clinical outcomes in dentistry were performed in databases up to January 2022. Two reviewers independently screened titles/abstracts, selected full texts, and extracted the data. The adherence to PRISMA-NMA reporting guideline, the AMSTAR-2 methodological quality tool, and the ROBIS risk of bias tool were assessed in the studies. Correlation between the PRISMA-NMA adherence and the AMSTAR-2 and ROBIS results was also investigated. Sixty-two NMA studies were included and presented varied methodological quality. According to AMSTAR-2, half of the NMA presented moderate quality (n = 32; 51.6%). The adherence to PRISMA-NMA also varied. Only 36 studies (58.1%) prospectively registered the protocol. Other issues lacking of reporting were data related were data related to the NMA geometry and the assessment of results consistency, and the evaluation of risk of bias across the studies. ROBIS assessment showed a high risk of bias mainly for domains 1 (study eligibility criteria) and 2 (identification and selection of studies). Correlation coefficients between the PRISMA-NMA adherence and the AMSTAR-2 and ROBIS results showed moderate correlation (rho < 0.6). Overall, NMA studies in dentistry were of moderate quality and at high risk of bias in several domains, especially study selection. Future reviews should be better planned and conducted and have higher compliance with reporting and quality assessment tools.

A Cross-Sectional Evaluation of Dental Professional's Knowledge of Locally Delivered Antimicrobial Agents and their Application in Periodontal Practice

Introduction

Dentists must employ locally delivered antimicrobial agents (LDAs) in a way that is in line with current recommendations from the scientific literature and the guidelines set by professional organizations. Considering the dearth of research on this topic, it is not known what strategies are adapted when using LDAs in their periodontal practice. So, the purpose of this research was to investigate how LDAs are utilized by dental professionals in their distinct periodontal practices.

Materials and Methods

This cross-sectional study used a closed-ended questionnaire. Dental professionals received electronic copies of the eight-item questionnaire. The questionnaire assessed the relevance of LDAs, how frequently they are used, which ones are used most, the number of patients who receive them, their understanding of pharmacological activities, and their knowledge of current treatment guidelines. The questionnaire's validity and reliability were evaluated before being presented to participants. Using the Statistical Package for the Social Sciences (SPSS), the input was analyzed.

Results

A total of 120 dental professionals, with an average age of 34.7 years, answered the questionnaire. Half of these individuals have no history of ever using LDAs. The most frequent LDA used in its different forms was chlorhexidine gluconate (CHX), followed by tetracycline. The majority of participants placed LDAs (80%) in less than 10 patients. Less than half acknowledged the different LDAs and their pharmacological activities. Not even 70% of clinicians were up-to-date on the current European Federation of Periodontology (EFP) guidelines. None of the participants discounted the significance of LDAs in periodontal care.

Conclusion

Dental professionals regard LDAs as essential to periodontal therapy. Yet, they lacked knowledge about general, pharmacological, and clinical aspects. The patient experience with LDAs was limited by an inappropriate deployment pattern.

Local drug delivery in the treatment of furcation defects in periodontitis: a systematic review

OBJECTIVES

To evaluate the effect of subgingival administration of various antimicrobials and host-modulating agents in furcation defects as an adjunct to scaling and root planing (SRP) compared to SRP alone or combined with placebo.

METHODS

A systematic review was carried out using MEDLINE-PubMed, Embase, and Scopus for articles up to October 2022 in addition to hand searches. All longitudinal studies that evaluated the effect of subgingival application of antimicrobial and host-modulating agents in furcation defects as adjuncts to SRP compared to SRP alone or SRP + placebo with at least 3 months of follow-up were eligible for inclusion.

RESULTS

A total of eight studies were included. Superior clinical treatment outcomes were shown when alendronate, rosuvastatin, boric acid, simvastatin, and tetracycline (only at 3 months) were utilized in furcation defects in conjunction with SRP alone or SRP + placebo. Significant improvement was reported in radiographic bone defect depth and defect depth reduction when SRP was supplemented with alendronate, rosuvastatin, boric acid, and simvastatin.

CONCLUSIONS

Within the limitations of this review, the adjunctive subgingival administration of medications and host-modulating agents in furcation defects may confer additional clinical and radiographic benefits than non-surgical periodontal treatment alone. Future investigations are needed to confirm their long-term effectiveness.

CLINICAL RELEVANCE

Local host modulators and antimicrobials may be used supplementary to enhance the clinical and radiographic treatment outcomes of conventional periodontal therapy in furcation defects.

THE EFFECT OF COENZYME Q10 ON PERIODONTITIS: A SYSTEMATIC REVIEW AND META-ANALYSIS OF CLINICAL TRIALS

OBJECTIVE

Coenzyme Q10 gel might be beneficial for periodontitis. However, the results have been controversial. We designed a systematic review and meta-analysis to explore the efficacy of coenzyme Q10 in periodontitis patients.

MATERIALS AND METHODS

A systematic review of controlled trials (PROSPERO: CRD42020212424) was performed from 1980 to August 2020 by 2 separate investigators through the following databases: Embase, CENTRAL, PubMed/MEDLINE, Scopus, Web of Science, Google Scholar, and ProQuest. Hand search of reference lists of the included studies was also performed. Of 269 records, eleven trials were included in the meta-analysis using a random-effect model.

RESULTS

Coenzyme Q10 could significantly reduce Plaque Index (SMD, -0.64; CI, -1.03 to -0.26, P = .002; I2 = 85.7%), Bleeding Index (SMD, -1.05; CI, -1.70 to -0.41, P = .001; I2 = 89.5%), Pocket Depth (SMD, -0.96; CI, -1.35 to -0.58, P ˂ .001, I2 = 84.7%), clinical attachment level (SMD, -0.73; CI, -1.23 to -0.22, P = .005; I2 = 87.8%), and gingival index (SMD, -0.63; CI, -0.97 to -0.28, P = .001; I2 = 72.8%) in periodontitis. Subgroup analysis showed that coenzyme Q10 had a stronger reduction effect if administered intra-pocket rather than topical. Studies with high risk of bias reported a greater positive effect of coenzyme Q10 compared to studies with unclear risk.

CONCLUSIONS

Our findings encourage administration of coenzyme Q10 gel in periodontitis based on its meaningful effect on Plaque Index, Bleeding Index, gingival index, clinical attachment level and Pocket Depth. Future studies with better qualities are required for a better conclusion.

Clinical Efficacy of Repeated Applications of Local Drug Delivery and Adjunctive Agents in Nonsurgical Periodontal Therapy: A Systematic Review

The aim of this systematic review is to compare the clinical efficacy of repeated applications of local drug delivery and adjunctive agents (LDAs) in nonsurgical periodontal therapy (NSPT) compared to subgingival mechanical debridement (SMD) alone. The Cochrane Central Register of Controlled Trials, MEDLINE, PubMed, EMBASE, Web of Science, hand-searched literature and grey literature databases were searched for randomized controlled clinical trials (RCTs) with a minimum of 6-month follow-up. The outcomes of interest were changes in probing pocket depth and clinical attachment level as well as patient-centred outcomes. Of 1094 studies identified, 16 RCTs were included in the qualitative analysis. Across 11 different adjuncts analysed, only two studies utilizing minocycline gel/ointment and antimicrobial photodynamic therapy (aPDT) with indocyanine green photosensitizer had statistically significant differences in primary outcomes when compared to their control groups. Only one study on aPDT methylene blue 0.005% had compared single versus multiple applications against its control group. A mean range of 0.27-3.82 mm PD reduction and -0.09-2.82 mm CAL gain were observed with repeated LDA application. Considerable clinical heterogeneity and methodological flaws in the included studies preclude any definitive conclusions regarding the clinical efficacy of repeated LDA applications. Future RCTs with a direct comparison between single and repeated applications should be conducted to confirm or refute the clinical advantages of repeated LDA application in the nonsurgical management of periodontitis.

Effect of locally delivered adjunctive antibiotics during surgical periodontal therapy: a systematic review and meta-analysis

Aim

The present study aimed to systematically assess current evidence on effects of locally delivered antibiotics during periodontal surgery compared to periodontal surgery alone on clinical attachment level (CAL) gain, probing pocket depth (PPD) reduction, recession depth (RD) changes, gingival index (GI), bleeding on probing (BOP), and plaque index (PI).

Methodology

MEDLINE-PubMed, Cochrane-CENTRAL and Scopus databases were searched up to April 2021 for randomized clinical trials (RCT), evaluating effects of locally delivered antibiotics during periodontal surgery. CAL gain served as primary, while PPD reduction, RD changes, GI and PI as secondary outcomes. The Cochrane Risk of Bias Tool was used to assess possible bias. Data were extracted, and meta-analysis was performed where appropriate.

Result

Screening of 2314 papers resulted in nine eligible studies. No adverse events were reported. Data on outcome variables were pooled and analyzed using generic inverse variance model and presented as weighted mean difference (WMD) and 95% confidence interval (95% CI). Statistically significant improvements in favor of antibiotics’ delivery were observed in studies with follow-up of ≤6 months for CAL gain (WMD = 0.61 mm (95% CI [0.07, 1.14]; p = 0.03), PPD reduction (WMD = 0.41 mm (95% CI [0.02, 0.80]; p = 0.04)) and BOP (WMD = −28.47% (95% CI [−33.00, −23.94]); p < 0.001), while for GI improvements were notable for >6 to 12 months (WMD = −0.27 (95% CI [−0.49, −0.06]; p = 0.01)).

Conclusion

Within the current review’s limitations, locally delivered antibiotics during surgical periodontal therapy results in post-surgical improvements for CAL, PPD, and BOP (≤6 months) with a longer-lasting GI improvement. Further randomized controlled trials are needed with true periodontal end-points to assess the ideal antibiotic agent, dosage, and delivery methods.

Clinical relevance

Local delivery of antibiotics during periodontal surgery improved clinical parameters for up to 6-month follow-up, with beneficial longer effects on gingival inflammation. Within the current study’s limitation, the presented evidence could support the elective usage of locally delivered antibiotics during surgical periodontal therapy.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00784-021-04056-7.