Change in clinical parameters after subgingival instrumentation for the treatment of periodontitis and timing of periodontal re-evaluation: A systematic review and meta-analysis

AIM

To evaluate the changes in periodontal parameters (reduction in probing pocket depth [PPD], gain in clinical attachment level [CAL] and reduction in full-mouth bleeding on probing [BoP]) after subgingival instrumentation of periodontal pockets at different time points in systemically healthy patients suffering from periodontitis.

MATERIALS AND METHODS

Four databases were searched for RCTs that carried out subgingival instrumentation in periodontal pockets and evaluated PPD at a minimum of two consecutive time points other than baseline. The analysis was conducted for both all pocket depths and stratified for initially shallow (4-5 mm) and deep (≥6 mm) pockets and data were extracted for various time points, 1-2, 3-4 and 5-6 months. Weighted mean effects (WMEs) were calculated with 95% confidence interval (CI) and predictive intervals were calculated.

RESULTS

Twenty-nine RCTs were identified, and all of them were included in the meta-analysis. The results showed that for both shallow and deep pockets there was a small though clinically meaningful change between 1- to 2-month and 3- to 4-month time points and between these and 5-6 months.

CONCLUSIONS

In systemically healthy patients, the greater part of reduction in PPD and gain in CAL occurs within the first 1-2 months after subgingival instrumentation. However, additional benefits in terms of pocket depth reduction occur beyond these early time points.

Probing the salivary proteome for prognostic biomarkers in response to non-surgical periodontal therapy

AIM

This prospective study investigated the salivary proteome before and after periodontal therapy.

MATERIALS AND METHODS

Ten systemically healthy, non-smoking, stage III, grade C periodontitis patients underwent non-surgical periodontal treatment. Full-mouth periodontal parameters were measured, and saliva (n = 30) collected pre- (T0), and one (T1) and six (T6) months post-treatment. The proteome was investigated by label-free quantitative proteomics. Protein expression changes were modelled over time, with significant protein regulation considered at false discovery rate <0.05.

RESULTS

Treatment significantly reduced bleeding scores, percentages of sites with pocket depth ≥5 mm, plaque and gingival indexes. One thousand seven hundred and thirteen proteins were identified and 838 proteins (human = 757, bacterial = 81) quantified (≥2 peptides). At T1, 80 (T1 vs. T0: 60↑:20↓), and at T6, 118 human proteins (T6 vs. T0: 67↑:51↓) were regulated. The salivary proteome at T6 versus T1 remained stable. Highest protein activity post- versus pre-treatment was observed for cellular movement and inflammatory response. The small proline-rich protein 3 (T1 vs. T0: 5.4-fold↑) and lymphocyte-specific protein 1 (T6 vs. T0: 4.6-fold↓) were the top regulated human proteins. Proteins from Neisseria mucosa and Treponema socranskii (T1 vs. T0: 8.0-fold↓, 4.9-fold↓) were down-regulated.

CONCLUSIONS

Periodontal treatment reduced clinical disease parameters and these changes were reflected in the salivary proteome. This underscores the potential of utilizing saliva biomarkers as prognostic tools for monitoring treatment outcomes.

Subgingival instrumentation

The S3-level clinical guidelines for the treatment of patients with periodontitis stages I-III published by the European Federation of Periodontology in 2020, suggest a pre-established stepwise approach for oral-healthcare professionals with precise therapeutic pathways. The second step of this approach consists of the subgingival instrumentation of periodontal pockets by non-surgical means to disrupt the microbial biofilm and remove soft and mineralized deposits This step aims to resolve periodontal inflammation by closure of periodontal pockets (probing pocket depth ≤ 4 mm, absence of bleeding on probing) employing different types of instruments and treatment protocols toward this end. Novel non-surgical treatment approaches that adopt micro instruments or subgingival application of biological agents have been recently tested. Subgingival instrumentation has been shown to effectively restore the subgingival microbiota to one associated with periodontal health and to modulate the inflammatory response. The outcomes of the subgingival instrumentation have to be evaluated in order to guide the therapist in providing additional but focused treatment in the remaining pockets OR at sites with residual inflammation. Of great importance is the impact that non-surgical periodontal treatment has on the patient's well-being, based on evidence that emerges from studies evaluating patient related outcomes and quality of life.

Additional benefit of systemic antibiotics in subgingival instrumentation of stage III and IV periodontitis with Aggregatibacter actinomycetemcomitans: A retrospective analysis

AIM

To evaluate subgingival instrumentation (SI) in periodontitis stage III and IV, grade B and C with systemic antibiotics (AB) only after detection of Aggregatibacter actinomycetemcomitans.

MATERIALS AND METHODS

Patients of the Department of Periodontology of Goethe University Frankfurt/Germany were screened for microbiological testing between 2008 and 2018. All patients with aggressive and generalized severe chronic periodontitis were tested. In case of positive subgingival A. actinomycetemcomitans tests, SI was combined with AB; in all other cases it was not (nAB). Clinical examinations were performed before (T0), 12.4 (9.4/15.1) weeks after SI (T1), and at the last supportive periodontal care (T2; 3.1 [1.4/5.5] years after T1). Results at T1/T2 were assessed as "treat-to-target" endpoint (≤4 sites with probing pocket depths ≥5 mm).

RESULTS

Four-hundred and twenty-five patients (280 stage III/145 stage IV, 95 grade B/330 grade C) provided complete data (AB 144/nAB 281) for T0 and T1, and 332 (AB 121/nAB 211) for T2. At T1/T2, AB resulted in 53 (37%)/76 (63%) patients with "treat-to-target" endpoint, and nAB in 76 (27%)/91 (43%) (p = .038/.001).

CONCLUSIONS

In periodontitis stage III and IV, grade B and C with subgingival A. actinomycetemcomitans infection, SI with AB resulted in higher rate of "treat-to-target" endpoint than exclusive SI in patients without the infection.

A systematic review

OBJECTIVES

To evaluate the efficacy of subgingival instrumentation (PICOS-1), sonic/ultrasonic/hand instruments (PICOS-2) and different subgingival instrumentation delivery protocols (PICOS-3) to treat periodontitis.

METHODS

Systematic electronic search (CENTRAL/MEDLINE/EMBASE/SCOPUS/LILACS) to March 2019 was conducted to identify randomized controlled trials (RCT) reporting on subgingival instrumentation. Duplicate screening and data extraction were performed to formulate evidence tables and meta-analysis as appropriate.

RESULTS

As only one RCT addressed the efficacy of subgingival instrumentation compared with supragingival cleaning alone (PICOS-1), baseline and final measures from 9 studies were considered. The weighted pocket depth (PD) reduction was 1.4 mm (95%CI: 1.0 1.7) at 6/8 months, and the proportion of pocket closure was estimated at 74% (95%CI: 64-85). Six RCTs compared hand and sonic/ultrasonic instruments for subgingival instrumentation (PICOS-2). No significant differences were observed between groups by follow-up time point or category of initial PD. Thirteen RCTs evaluated quadrant-wise versus full-mouth approaches (PICOS-3). No significant differences were observed between groups irrespective of time-points or initial PD. Five studies reported patient-reported outcomes, reporting no differences between groups.

CONCLUSIONS

Nonsurgical periodontal therapy by mechanical subgingival instrumentation is an efficacious means to achieve infection control in periodontitis patients irrespective of the type of instrument or mode of delivery. Prospero ID: CRD42019124887.

Streptococci in the Subgingival Biofilm and Periodontal Therapy

Purpose: The aim of this study was to verify how the prevalence of viridans-streptococci is changed by two appointments of professional prophylaxis and after the subgingival instrumentation via scaling and root planing (SRP). Material and Methods: Samples of the subgingival biofilm were collected from 19 individuals with periodontitis receiving two appointments of professional prophylaxis and SRP before and after the treatment procedures and the presence of viridans-streptococci was analysed by microbiological cultivation. Non-parametric statistical testing using Friedman/Wilcoxon tests and chi-square testing was used for statistical analysis. Results: No statistically significant changes over time were found for the mutans-group. The prevalence of Streptococcus mitis decreased after two appointments of professional prophylaxis (p = 0.013). The prevalence of S. mitis decreased again after SRP (p &lt;0.001). The prevalence of Streptococcus anginosus decreased after two appointments of professional prophylaxis (p = 0.002). After SRP five positive results for S. anginosus were detected (p = 0.026). For Streptococcus oralis and Streptococcus gordonii tendencies to statistical significance were found. The number of positive results for S. oralis increased after the first appointment of professional oral prophylaxis (p = 0.055). The number of positive results for S. gordonii increased after the first appointment of professional oral prophylaxis (p = 0.055). Conclusion: The step-wise periodontal therapy influences the prevalence of viridans-streptococci, especially S. mitis and S. anginosus. No tremendous increase of streptococci especially related to the carious process occurs in the subgingival biofilm. Clinical Relevance: The study reveals knowledge on changes of the composition of the subgingival biofilm due to different steps of periodontal therapy.