Proximal Cleaning
Which proximal cleaning agents are the most effective?
Does the type of floss matter?
Oral Irrigators
Are oral irrigators beneficial or detrimental?
Keyes Technique
Is the Keyes technique more effective than traditional oral hygiene? Prove it!
What are the bases for the Keyes technique of oral hygiene?
Pocket Irrigation
Which medicaments have been shown to be beneficial when used as subgingival pocket irrigants?
How far sub-gingivally will oral irrigants reach?
Local Drug Delivery
Will you use local delivery systems in your practice? Why? Why not? Under what circumstances?
PerioChip
Arestin (Ora Pharma)
Host Modulation with Sub-Antimicrobial Dose of Doxycycline (Periostat, Collagenex)
Proximal Cleaning
Which proximal cleaning agents are the most effective?
Does the type of floss matter?
Jackson 2006: ARTICLE
P: To compare the effects of a customized interdental brushing technique and a customized flossing technique on clinical periodontal outcomes prior to root surface debridement in chronic periodontitis cases.
M&M: Single-blind randomized controlled clinical trial. 77 pts with chronic periodontal disease were measured for plaque, relative interdental papillae level (RPIL), Eastman interdental bleeding index, PD’s, BOP at interdental sites, and underwent 10 min hand scaling to remove easily accessible calculus deposits. Before group allocation, all pts were instructed on how to brush and were given a standardized toothbrush and toothpaste. Pts were also instructed in 2 customized methods of interdental cleaning involving floss and precurved interdental brushes and were randomly assigned a group. 1 hygienist evaluated all pts. Pts were recalled at 6 and 12 weeks.
R: There were SSD reductions from baseline for all indices in both groups. At 6 wks, the interdental brush group improved more than the floss group in every parameter. At 12 weeks, the changes in plaque, papillae level, and PD were significantly greater in the interdental brush group when compared to floss group.
| Clinical Variable | Brushing Change - BL to 12 wks | Flossing Change BL to 12 Wks |
| PI | 0.40 * | 0.17* |
| RIPL | -0.99* | -0.59* |
| PD | 0.56* | 0.31* |
| EIBI | 0.33 | 0.24 |
| BOP | 0.29 | 0.23 |
* Statistically significant between brushing and flossing groups
BL: At 6 and 12 weeks there was significantly greater reduction with interdental brush group when compared to flossing group.
Waerhaug 1981 ARTICLE
Purpose: To assess the effect of dental floss in children with healthy gingiva.
M & M: 28 1st premolars scheduled for extraction in 7 children 12 y/o. Floss was inserted into the pocket on mesial (M) until pressure was felt and was moved back and forth 3 - 5 times. Teeth were extracted after varying observation periods (15 min, 24 h, 3days, 1wk, 2wks, and 3wks)
Results: The floss was brought 2 - 3.5 mm below the tip of the papillae. The control surfaces (distal) were covered with a more or less continuous layer of JE, whereas such cells were absent on the experimental side with observation periods of 15 min & 24 hrs. The JE cells started to reappear on the enamel after 3 days, & after 2 wks, there was no difference. In 1 pt that used the floss daily for 3 1/2 months, there was no reattachment, but nothing-indicated unfavorable consequences.
Conclusion: Floss caused detachment of the JE. The disruption of the JE by the use of dental floss may be classified as a physiological event rather than a pathological condition.
Graves 1989 ARTICLE
P: to determine effectiveness of 3 types of dental floss versus toothbrushing in reducing interproximal bleeding sites using the interdental bleeding index assessment method.
M&M: 119 non-flossing patients with at least 10 interproximal bleeding sites were divided into 1 of 4 groups. Groups 1-3 (waxed floss, unwaxed floss, & dental tape) were instructed on the use of a different type of floss while group 4 had toothbrushing only (2X/day). Subjects returned daily for 2 weeks for supervised brushing or flossing.
R/BL: All groups showed lower bleeding scores at the end of 1 week, with 3 flossing groups having sig less than toothbrush only group. At 2 weeks, Toothbrush (group 4) only showed decrease in bleeding score of 35% while the flossing groups showed a decrease of about 67%. There was no SSD between the type of floss.
Interdental bleeding index assessment: Caton. Wooden toothpick inserted and removed 4 x in horizontal direction from buccal, depressing papilla 1-2mm. look for 15 seconds for bleeding. Indicates ging inflamm. Bleeding index # bleeders/#stimulated.
Critique: This is a short clinical trial (2 weeks). Also, flossing was supervised which could lead to Hawthorne effect (better results b/c they know they are being observed.
Lamberts 1982 ARTICLE
P: To determine the effectiveness of waxed and unwaxed floss in plaque removal when used in a home oral hygiene program.
M&M: 80 patients (15M/29F, 22-79years) who had previously received periodontal treatment and were on maintenance participated in the study. Patients were divided into 4 groups (Butler waxed/unwaxed—Johnson & Johnson waxed/unwaxed). All patients were required to have 6 Ramfjord (#3, 9, 12, 19, 25, 28). After receiving prophylaxis, each patient received OHI with a video tape and was given toothbrush and test floss. At 0, 28, and 56 day intervals PI, GI and bleeding index were recorded.
R: NSD for mesial and distal surfaces of each tooth for plaque or gingivitis scores. No difference between different brands or different types of floss.
C: No SSD among the 4 types of tested floss in plaque removal and prevention of gingivitis.
Ciancio 1992 ARTICLE
P: To evaluate the effectiveness of a waxed dental floss (Johnson & Johnson) compared to ePTFE floss (Glide) on plaque reduction.
M+M: 60 subjects (18-63 yrs old) equally divided: 30 pts used control floss and 30 pts used experimental (Glide). Initial measurements were taken, and the pts were instructed to perform normal oral hygiene and floss 1x/day. Pts were also given a toothbrush and dentifrice, but no other cleaning methods were used. Measurements of modified GI, PI, and bleeding index at 0, 2, 5, and 6 weeks. At week 5, the pts were assigned the opposite floss for 1 week of use for determination product preference.
R: NSSD at any time interval for PI or modified gingival index. A SS reduction in bleeding index was observed for the ePTFE floss at week 2 compared to the nylon waxed floss (avg of 0.23 +/- 0.13 bleeding sites/pt, a 56% reduction, vs. 0.35 +/- 0.19 bleeding sites/pt, 39.1% reduction). There was NSSD at other time intervals. 74.5% of the study group preferred the ePTFE floss and 24% preferred the waxed floss.
BL: Pts preferred the ePTFE floss due to ease of use and lack of fraying or shredding. However, there is no SSD between the 2 types of floss clinically.
Carr 2000 ARTICLE
P: To evaluate the efficacy of four different floss types (waxed, unwaxed, woven, shred -resistant) for interproximal plaque removal on the normal dentition.
M&M: 24 oral hygiene students, with a minimum of 26 permanent teeth (non-restored), no PD>4mm, no recession or embrasure spaces participated in the study. At baseline, all students received prophy and identical flossing instructions. They were then instructed not to floss, brush or rinse for 3 days to allow for plaque development. On the fourth day, teeth were disclosed and were scored using O’Leary’s PI. Students were then randomly assigned one of the four floss types to use throughout the entire dentition, without a mirror. After that, a second plaque control record was assessed. Students were timed while flossing and they completed a VAS scoring their degree of discomfort /comfort and ease of use for the specific type of the floss used.
R: The results analyzed percent reductions in total interproximal plaque score (TIPS), anterior interproximal plaque score (AIPS), and posterior interproximal plaque score (PIPS). Buccal and lingual scores were not assessed. All interproximal surfaces were included except for 3rd molars and distal of second molars. The greatest reduction in TIPS (68.87%) and PIPS (66.54%) was with waxed floss and in AIPS with woven floss (75.15%). There was no significant difference among the four floss types. VAS scores revealed shred-resistant the most comfortable (6.99) while unwaxed was least comfortable (4.29). The differences among the four floss types in the degree of comfort and time were not significant, however, unwaxed floss received the most amount of negative feedback.
BL: No significant difference in the degree of plaque removal between the four different floss types. It’s a matter of personal preference which type of floss one should use.
Isaacs 1999 ARTICLE
Purpose: To compare the efficacy and safety of the Braun Oral-B Interclean interdental cleaning device to an ADA-accepted waxed dental floss.
Materials and methods: 170 subjects 18 years and older, 127 women and 43 men with interproximal plaque scores greater than 2 and no periodontal disease. Subjects were generally healthy, had at least 16 natural teeth, and used floss no more than once a week. Pts taking anti-inflammatory drugs, analgesics or anticoagulants, those that had taken antibiotics within seven days of recruitment, or if they had history of hepatitis, tuberculosis, rheumatic fever or needed antibiotic prophylaxis were excluded. Pregnant women were also excluded and subjects were prohibited to use antimicrobial mouthwash or receive dental prophylaxis during the study.
Six month randomized, single-blinded, parallel group study. All subjects received prophylaxis and instructions about device or floss. Interproximal plaque score, gingival index and gingival bleeding recorded at base line, 3 and 6 months for all natural teeth except three molars. After baseline examination subjects received dental prophylaxis. Subjects were requested to refrain from oral hygiene practices after midnight on the night before all oral examinations to allow plaque to accumulate. At 6 months a single use evaluation of plaque removal was performed, after the plaque that accumulated overnight was assessed, subjects used their assigned product unsupervised following by manual tooth brushing and then they were re-evaluated.
Results: 147 subjects completed the study. Interdental device group: 21 mean and 64 women and floss group 22 men and 63 women. No evidence of soft or hard tissue abrasion. At base line, normal looking soft tissue in 87.1% (74 subjects) of interdental device group and 92.9% (79 subjects) of the floss group. At 6 months, this parameter was observed in 89% in both groups. Reduction in plaque score was 18.3% for interdental device and 18.8% for floss- was not statistically significant. One time efficacy was comparable between the two groups.
Conclusion: Benefits are similar when using interdental cleaning device and floss with respect to plaque removal and gingival health. Authors suggest that the electric interdental cleaning device may benefit patients, especially those who lack the motivation to use floss as part of their daily oral hygiene efforts.
Tu 2008 ARTICLE
Purpose: The aim of this study was to re-analyze data from Randomized controlled trials (RCT) which compared two interdental cleaning methods with multiple outcome measured at three occasion.
Materials and methods
This RCT compared the effects of a novel customized interdental brushing technique, with pre-curved brushes, and a customized flossing technique.
77 pts with chronic periodontitis (39 interdental brushing, 38 control flossing) clinical measurements recorded at baseline, 6, 12 weeks.
3 main outcomes variables chosen for analysis with Latent Growth curve modeling (LGCM): Probing Pocket depth (PPD), plaque indices, BOP
Univariable LGCM: PD, plaque indices, BOP.
Explanatory variables were smoking and brush.
Direct and indirect effects in multivariable LGCM
Results:
Most changes occurred during the first 6 weeks
Test group: Greater reduction in PD, plaque indices and BOP than control (flossing)
No substantial differences in PD and plaque indices between smokers and non-smokers
Pts with higher baseline plaque indices had greater PD and tendency to BOP.
The direct effect of different cleaning methods on pocket reduction was relatively small, compared with the indirect effects through changes in plaque indices
Smokers had lower percentage of BOP at baseline, but less improvement on BOP.
Discussion
Previous analysis of this RCT by univariable found that pts using interdental brushing technique showed greater improvement in PD, plaque indices and BOP than those flossing
However univariable statistics cannot disentangle the direct and indirect effects of different oral hygiene methods on the change of PD
In this study, we used LGCM to show that the greater reduction in pocket depth and bleeding on probing in persons who used the interdental brushing technique was due mostly to the greater efficiency of interdental brushing in removing dental plaque.
Smoking seemed to have a direct effect upon bleeding on probing, but little effect on both changes in pocket depth and plaque indices, directly or indirectly
Oral Irrigators
Are oral irrigators beneficial or detrimental?
Greenstein 2000 (review) ARTICLE
P: To address the advantages and limitations of nonsurgical periodontal therapies to treat patients with mild-to-moderate chronic periodontitis.
D:
Mechanical Hand Instrumentation:
Mechanical instrumentation with hand currettes is effective tx for pts with mild-mod perio (CAL of less than 5mm). Studies report root planning (RP) can reduce PDs, gain CAL, and inhibit disease progression. An increase in clinical attachment refers to new CT attachment (periodontal fibers inserting into the cementum) or formation of a LJE (repair). Usually repair occurs.
Cobb1996 review calculated mean PD reduction and CAL gain that can be achieved with RP. Sites initially 4-6mm in depth had mean PD reduction of 1.29mm and CAL gain of 0.55m. Sites with 7mm or greater depth, had PD reduction of 2.16mm and CAL gain of 1.29mm. The decrease in PD consisted of two components: gain in CAL and recession. As rule of thumb, we can expect the gain of CAL about half of the PD reduction. After root planning, should assess in 4-6 wks. After 6 wks most healing has occurred, but repair continues for an additional 9 months.
Studies show that predictability of removing subg deposits decreases with increasing PDs. Caffesse 1986 demonstrated that when pockets exceeded 5mm, deposits were removed completely only 32% of the time. With respect to angular osseous defects, Cobb found that limited bone fill occurred subsequent to RP. Non surgical therapy is not effective in suppressing Aa because it is tissue invasive, need to consider abx therapy for those pts.
Ultrasonic Debridement:
Term “ultrasonic debridement” refers to the removal of root-surface accretions with a vibrating mechanical device. Its purpose is to resolve inflammation in the adjacent soft tissues. This is different than RP, which involves removal of root accretions and cementum down to a smooth hard surface. Studies show similar results in PD reduction with ultrasonic debridement and hand SRP. Ultrasonic debridement results in less dentinal hypersensitivity and involves less chair time and operator fatigue. Problem with ultrasonic is development of aerosols that contain blood and bacteria. Aerosols develop within several feet of the operator and remain in the air for approx. 30 mins. Clinicians should wear a mask, use high speed suction, and ask pts to do a pre-procedural rinse to reduce amt of bacteria in their saliva.
Supragingival Irrigation:
6 well-designed studies have indicated that supragingival irrigation enhanced the effects of toothbrushing and reduced gingival inflammation in pts who did not
perform good oral hygiene.
Reduction in inflammation ranges from 6.5-54%. Occurs because of a decreased amount of suprag plaque and secondary subg penetration of irrigants, which flush bacteria out of pockets. Lang 1981 showed that 0.02% CHX delivered with an irrigator achieved a clinical result similar to that with 0.2%, with reduced staining. This concentration can be formulated by diluting 0.12% CHX with 5 parts water.
Subgingival Irrigation:
Eight Studies indicated that irrigation did not enhance the therapeutic effect attained with SRP alone.
Local Drug Delivery:
Studies show similar results for PD reduction and CAL gain (approx. 1mm) with SPR alone or LDD (TCN fibers, Metro Gel, Doxy, CHX chips). The benefits of LDD include its ability to deliver drugs deep within the pockets at a bactericidal or bacteriostatic concentration, and that elevated concentration can be maintained for a long period of time. Periochip and Atridox have two device characteristics that are highly desirable: resorbability and controlled release of the drug. Use of LDD as monotherpay is controversial, since RP alone achieves similar results. LDD should be reserved for sites in patients that fail to respond to mechanical instrumentation. Also, before using LDD, it is important to SRP the root surface of teeth to disrupt the subg biofilms and remove calculus.
Systemic Antibiotic Therapy:
Should be avoided in the routine treatment of chronic perio. Abx indicated in: ongoing disease progression despite meticulous mechanical intstrumentation, refractory chronic or aggressive periodontitis related to persistent subgingival pathogens or impaired host resistance, and acute infections. Also, can be appropriate for certain medically compromised patients. Systemic Abx are good for those patients infected with Aa (abx delivered via serum to the base of the pocket and can effect invasive Aa and other organisms). Can also affect reservoirs of bacterial reinfection-- the saliva, tonsils, and mucosa (Greenstein, Slots).
If Aa suspected organism, combo of Amoxicillin with Clavulanic acid [Augmentin] and Metronidazole, an abx specific for obligate anaerobes (van Winkelhoff). If pt allergic to PCN, Ciprofloxacin should be substituted (effective against enteric rods, pseudomonads, and staph). Also Clindamycin is specific for anaerobes.
Host Modulation:
Periostat is a collagenase inhibitor that consists of 20mg capsule of doxycycline hyclate for oral admin. It is administered at such a low level that it has no bacteriostatic activity. Its purpose is to reduce collagenase activity in patients with periodontitis. Caton 2000 showed that use of subantibacterial dosing with Doxycycline (SDD) of nine months duration plus RP has resulted in a small, but significant clinical improvement over root planning alone. 4-6mm PD: CAL gain of 1.03mm after SRP + SDD, 0.86mm after SRP alone, difference of 0.17mm. 7mm+ PD: CAL gain of 1.55mm after SRP + SDD, 1.17mm after SRP alone, difference of 0.8mm. 4-6mm PD: PD reduction was 0.95mm after SPR + SDD and 0.69mm after SRP alone, difference of 0.26mm. 7mm+ PD: PD reduction 1.68mm after SRP + SDD and 1.20mm after SRP alone, difference of 0.48mm. Important to note that drug admin is not a substitute for SRP and appropriate tx designed to minimize bacterial load and facilitate proper OH.
C: The data indicate that most patients with mild-to-moderate periodontitis can be treated with nonsurgical therapies. However, clinicians need to be aware of the limitations of each technique with regard to the magnitude of improvement that it can induce at specific sites.
Greenstein 2005 ARTICLE
P: Position paper – The role of supra- and subgingival irrigation in the treatment of periodontal diseases
D: Supragingival irrigation
1) With water as a monotherapy – controversial in plaque reduction. Several studies indicated that it was unable to resolve gingivitis and was inferior to toothbrushing.
2) With water combined with toothbrushing – mixed results. Several studies consistently demonstrated improved periodontal status. Patients who demonstrate proficient toothbrushing and have no gingivitis may not need adjunctive irrigation therapy.
3) With water vs. rinsing with medicaments – mixed results in short term studies. More studies needed to confirm.
4) With antimicrobial agents – consistently improved clinical and microbiologic parameters in individuals with gingivitis. It delivered medicaments interproximally more effectively than rinsing. - Penetration of solution: Supragingival irrigation can project solutions subgingivally about 3 mm or to half the probing depth.
- Induction of bacteremia: It presents no particular safety hazard to systemically healthy patients, because similar levels of bacteremia were detected after toothbrushing, flossing.
Subgingival irrigation
- Penetration of drugs into pockets: 90% pocket penetration when PDs were < 6 mm
- Pathogen reduction: Can reduce, but not eliminate.
- Improvement of clinical parameters: Decreased PI, but failed to completely eliminate signs of inflammation.
- Additive effect: Controversial. Some studies showed synergistic effect, but the result was minimal.
- Ultrasonic debridement with and without antimicrobial agents as the irrigant: Several studies suggested that adjunctive use of PVP-I might enhance non-surgical periodontal therapy. Small sample sizes and clinically irrelevant difference underscore the need for additional evidence.
- Antimicrobials VS Placebo as irrigants: Mixed results.
- Professional VS Personal application: No long-term studies to compare. Many individuals may not have the dexterity to use. However, marginal irrigation that results in significant subgingival penetration has been successfully used by maintenance patients, and is a technique that is easy to master
Safety
- Supra- and subgingival irrigation have not produced any deleterious effects. However, it may be prudent to avoid these modes of therapy in pateints with gingivitis or periodontitis if they have a medical history which dictates that premedication is required prior to conventional therapy.
Keyes Technique
Is the Keyes technique more effective than traditional oral hygiene? Prove it!
What are the bases for the Keyes technique of oral hygiene?
Keyes 1978 I ARTICLE
Discussion: Initial report of the use of phase-contrast microscopy & chemotherapy in the diagnosis & treatment of periodontal lesions.
The rationale behind the diagnostic & therapeutic regimen is based on the following propositions:
Certain bacterial complexes attached to radicular surfaces are not compatible with health (motile bacteria)
WBC’s and bacteria residing in the sulcus-pocket spaces can be readily sampled & examined by phase-contrast microscopy
Certain bacterial populations can be used to predict periodontopathic conditions
Populations in question can be prevented from accumulating or can be suppressed by appropriate therapy
When bacterial populations are controlled, destruction of periodontal tissues diminishes greatly.
The procedural steps of microbiologically monitored and modulated periodontal therapeutics include:
- Clinical examination and microbial assessment consisting of phase contrast microscopic exam of subgingival plaque obtained from 2 or 3 of the most severely diseased sites using a sterile curette.
- Patient education involving information about role bacteria play in the initiation and progression of disease
- Keyes technique: consists of : brushing and flossing with a baking soda and peroxide paste and leave it after brushing for 1 minute (table salt can also be used & Epsom salt (MgSO4) should be used by patients on low sodium diet)
: Use of a water irrigation device with/without salt to reduce food residues, fluoride treatment (with gel) at bedtime. The effect of “salting out” of the bacteria is cease of motility (when contact with salt saturated solution).
: A microscopic evaluation is made at each visit. If patient continues to demonstrate a large number of motile bacteria and WBC, tetracycline 250 mg. q.i.d. for 14 days is prescribed to suppress spirochetes and motile rods. A phase contrast microscopy is performed at 2 weeks to check for the presence of spirochetes, motile rods and WBC's. The antibiotic is stopped, reduced or re-administered depending on findings.
Keyes 1978 II ARTICLE
Purpose: Follow up of Phase I report.
R/D: Microscopic findings indicate that large numbers of spirochetes, large motile rods and White Blood Cell counts (WBC) are associated with a disease state. In cooperative patients, the use of certain saturated salt solutions deep into the sulcus and periodic systemic tetracycline administration can result in:
1) decreased populations of spirochetes, large motile rods, and WBCs to non-detectable levels,
2) decreased gingival inflammation, bleeding, and suppuration and improvement in gingival contour and shape,
3) less mobility,
4) ceased resorption of bone,
5) PD remained same or decreased at 6 months to 1 year.
BL: The authors suggest diligent OH, with salts solutions and periodic systemic tetracycline. Periodic microscope assessments of gingival flora are essential for detecting potential pathogenic conditions prior to further tissue destruction.
Wolff 1989 ARTICLE
P: To evaluate effectiveness of homecare: conventional OH vs salt + H2O2 regimen.
M&M: 4 year longitudinal study, 171 subjects (71%M/29%FM), 20-64 years finished the study. Baseline clinical data scored on 8 teeth: 6 Ramfjord teeth + 2 deepest PD of remaining premolars or molars. Subjects then received SRP and OHI, and were randomly assigned to 2 groups 1) conventional OH (soft toothbrush and flossing) 2) 2x\day salt and peroxide regimen (mix sodium bicarbonate with 3 drops of 3% H2O2 +3 drops H2O to make a paste. This mixture was applied with a soft toothbrush and rubber tip. After brushing and flossing, an irrigating device (Water Pik) was used to irrigate the gingival areas with 400ml of a premixed saturated solution of NaCl. The two groups were balanced with respect to gender, age and severity of inflammation. Clinical parameters (PI, GI, PD, AL) rescored at 8, 16, 24, and 48months. Compliance and acceptance measured by questionnaire at 24 & 48months.
R: Plaque index reduced for both groups at either 8, 16, or 24 months, but by 48 months, returned to baseline. GI also returned to baseline by 48 months. Both groups had SS reductions in PDs and CAL gains at 8, 16, 24, and 48 months compared to baseline. NSD between conventional OH and antimicrobial home in clinical parameters associated with periodontal disease. There was less patient acceptance of the salt/peroxide regimen at 24 and 48 months.
BL: No difference in clinical parameters between the two groups. Higher levels of compliance and acceptance were observed in the group with conventional OH.
Pocket Irrigation
Which medicaments have been shown to be beneficial when used as subgingival pocket irrigants?
How far sub-gingivally will oral irrigants reach?
Shiloah 1993 ARTICLE
P: To review the available information on the efficacy of intrapocket irrigation in the treatment of patients with periodontitis. Addressing: 1) the penetrability of the irrigant, 2) pocket irrigation without SRP, 3) professional pocket irrigation following SRP, 4) irrigations between recalls and 5) safety of intrapocket irrigation.
D: According to ADA, AAP, and Council on Dental Materials, Equipment and Instruments guidelines subgingival irrigations must have:
A significant and sustained effect on the composition of subgingival plaque.
A positive and lasting effect on the clinical parameters of periodontitis.
A greater beneficial effect on periodontitis than SRP alone.
All irrigation techniques and all irrigants must be safe.
Based on these guidelines and review of literature:
Current oral irrigation devices do not consistently deliver solution to the most apical front of subgingival plaque.
Pocket irrigations alone do not eliminate inflammation and cannot substitute for SRP in tx of periodontitis. The persistence of inflammation may lead to additional bone and attachment loss.
Pocket irrigation following SRP does not augment the results obtained by root instrumentation alone. However, multiple irrigations with higher concentrations of antimicrobials such as 2% CHX have been reported to enhance the effect of SRP on both clinical and microbial parameters of periodontitis.
Simultaneous ultrasonic scaling and subgingival irrigation with antimicrobial agents holds promising potential. Additional research is required.
Daily irrigations with antimicrobial agents during the maintenance phase of perio therapy may improve the OH and the gingival health in patients with inadequate mechanical plaque control. Evidence is lacking to suggest that irrigations prevent repopulation of the pocket by pathogenic bacteria or decrease the frequency of the maintenance appointments. For this reason, pocket irrigation cannot substitute for periodic professional tooth instrumentation.
More research is needed if subgingival irrigation to gain an important role in tx of periodontitis:
Penetrability of the irrigant and maintenance of an effective concentration of the antimicrobial agent within the pocket.
The synergistic and antagonistic effects of different antimicrobial agents on the subgingival flora, and their impact on periodontal cells.
The role of subgingival irrigations alone or in conjuction with SRP on the repopoulation rate of the periodontal pocket.
Effects of different antimicrobial agents on the subgingival flora and their impact on periodontal cells.
The role of subgingival irrigation during the healing period following perio surgery.
Safety and efficacy of professional and patient administered irrigators.
Braun 1992 ARTICLE
P: To evaluate the depth of subgingival delivery in mild to moderate perio dz following use of a newly designed irrigation tip to be used in a powered oral irrigator.
M&M: Pts that needed extractions and had mild-moderate perio, but not undergoing active perio therapy and without abscesses were included. Pts with PDs 6mm or less were assigned to irrigation group or control group (supra-g rinse). Those with pockets of 7mm or greater were assigned only to the irrigation group for increased challenge of the delivery tip. A total of 145 sites were evaluated in 14 pts with 70 sites in the irrigation group (43 had pockets 
6mm, 27 pockets 
7mm) and 75 sites in the rinse (control) group. Sites evaluated were mesiobuccal, distobuccal and distolingual. The purpose of the rinse group was to determine penetration with rinsing only. GI and PI were recorded. In the subgingival irrigation group, an erythrosine solution was placed in the reservoir of the irrigating device. The irrigator was set at 3 (scale 1-5), producing and exit pressure of 23psi. The tip was held adjacent to the tooth surface at a 45-degree angle and was applied for 5 seconds per site. The control group rinsed for 30 seconds with the dye. Irrigation and rinsing were performed before the administration of anesthesia to allow irrigation to be discontinued if pt discomfort occurred. Reference grooves were placed with a bur at the gingival margin. The distance from the notch to the apical level of the dye on the root surface was measured with a probe.
R: The rinse group (mean 21%) had SS less penetration than the test group at all sites (1-3mm, 4-6mm, 7mm or greater). The mean depth for the test group was 90% for all sites 6mm or less. Lower penetration occurred as PD increased. Within the control group, there was SS greater penetration in the posterior pocket sites (NSSD between sites between any other group). Sites 7mm had a mean penetration of 64% (SS less than sites 
mm). NSSD between groups in GI/PI. No pts reported discomfort during the irrigation.
BL: When a special tip is used, oral irrigators can reach up to 90% in pockets 4-6mm, but only an average of 64% when the PD is 7mm or greater. Efficacy decreases as PD increases.
Eakle 1986 ARTICLE
Purpose: 1) To test the effectiveness of the Water Pik in delivering a solution of erythrosine dye to the depths of pockets in moderate and advanced periodontal lesions and 2) to evaluate the effect changing the angulation of the applicator tip in relation to the long axis of the tooth from 90 to 45 degrees has.
Materials and methods: 9 pts requiring extractions because of advanced periodontal diseases that had not received subgingival scaling or antibiotic therapy in the past 6 months were included. Group A consisted of 4 pts (9 posterior teeth) in which the irrigating solution was delivered with the tip angled at 90 O with respect to the long axis of the tooth. Group B had 5 pts (11 posterior teeth) and received irrigation at a 45O angle. PD were measured at 6 surfaces to the nearest mm one week before the extraction procedure in order no to disrupt the plaque. Pockets were divided into shallow (0-3mm), moderate (4-7mm) and severe (>7mm). At the extraction appointment, the teeth were notched at 6 reference points. An erythrosine plaque staining dye was used to indicate the extent of subgingival penetration of the solution delivered by the Water Pik. Each tooth was irrigated 6-8 s at a standard setting of 8 (approx. 70 psi). During extraction, care was taken to not instrument root surfaces and, data was not used if the surface had its plaque disrupted. Measurements were then taken to the nearest mm from the notch to the depth of dye penetration and connective tissue attachment (depth of pocket).
Results: Group A included 50 surfaces and group B included 65 surfaces. There were no significant differences between these groups in shallow, moderate or severe pockets, even when they were grouped into proximal or facial/lingual groups. There was also no significant difference between maxillary and mandibular teeth. For 90 O application, lack of tissue filing embrasure space had significantly greater penetration (62.6%) when compared to tissue-filled embrasure spaces (37.4%). This difference was not found for the 45 O group. In the 45 O group, there was significantly greater penetration of proximal pockets with edematous tissue than with firm tissue. Too few pockets with edematous tissue were irrigated in the other group to make a comparison. For the 90 O group, the mean % penetration was 71% for shallow, 44% for moderate, and 67% for deep pockets. The 45 O group had 54% for shallow, 46% for moderate, and 58% for deep pockets.
Conclusion: The Water Pik will penetrate to about half the pocket regardless if used at 45 or 90 degrees. Several factors made it difficult to accurately take measurements (length of epithelial attachment or dye may penetrate further into a plaque-free area)
Wennstrom 1987 (I) ARTICLE
Purpose: To study the effect of professionally performed sub-gingival irrigation and as an adjunct to scaling and root planing.
Materials and methods
10 pts with moderate to severe periodontitis, and 2 -3 interproximal sites with > 6mm probing depths and bleeding on probing were selected.
Oral hygiene instructions were given and both supragingival calculus and overhangs were removed.
Plaque index, gingival index, probing depths, probing attachment level, and bleeding on probing were recorded.
Bacterial samples were obtained from all experimental sites.
Treatment phase1 (duration 32 wks):
Quadrant A: Sub-gingival irrigation with 3% hydrogen peroxide
Quadrant B: Sub-gingival irrigation with 0.2% Chlorhexidine
Quadrant C: Sub-gingival irrigation with saline
Quadrant D: No sub-gingival irrigation (The control)
Treatment phase 2:
All sites were scaled, root planed, and the sub-gingival regions were irrigated except in the control sites. All measurements were repeated at the end of phase 2.
Results:
Treatment phase I:
At 32 weeks, all 4 treatments were similar
Probing depth reductions: saline 0.7 mm, chlorhexidine 0.6 mm, hydrogen peroxide 1.02 mm (SSD)
Probing attachment level: NSD between treatment groups; NSD from baseline
Bleeding on probing: All treatment groups showed a reduction with the hydrogen peroxide being higher
Treatment phase II:
Probing depth reduction: SSD for all treatment groups. 1.1-1.4mm reduction. The best was with hydrogen peroxide. The worst was the controls and saline.
Probing attachment level: SSD in all treatment groups: 0.5-0.8mm gains
Bleeding on probing: All groups showed reduction.
BL: Scaling, root planning, and supragingival plaque control resulted in a marked resolution of the clinical symptoms of periodontitis. Adjunctive irrigation with chlorhexidine or hydrogen peroxide did not improve the healing result beyond that obtained after mechanical debridement alone or in combination with saline irrigation.
Wennstrom 1987 II ARTICLE
P: To evaluate the effect of subgingival irrigation alone & subgingingival irrigation with mechanical debridement.
M&M: 10 patients with mod-severe periodontitis; 2-3 interproximal sites per various quadrants with PD of > 6 mm; divided into groups; irrigation with 0.2% CHX, with hydrogen peroxide, or with saline; Pocket irrigated every 2nd-3rd days during two 2-week periods separated by two weeks with no treatment (no mechanical debridement). Pockets in different quadrant served as controls with no irrigation. 6 months later, mechanical debridement + irrigation was done; subgingival microbiological & radiographic exam before and after phase 1 and phase 2.
R: Mechanical debridement resulted in almost complete removal of motile rods & spirochetes whether or not irrigation was used; irrigation decreased rods & spirochetes (especially when irrigated with Peroxide) initially. Numbers increased to baseline values by 32 weeks; mechanical debridement decreased viable bacteria count significantly (irrigation did not); no difference regarding radiographic bone changes in any groups.
BL: Mechanical debridement alone seems to be as effective in periodontal treatment as does debridement + irrigation. Irrigation alone does not seem to eliminate pathogenic microorganisms for an extensive period of time; therefore it is not a viable treatment modality.
Stabholz 1998 ARTICLE
P: To evaluate clinical and antimicrobial effects of a single episode of subgingival irrigation of Tetracycline (TCN) or Chlorhexidine (CHX) in the absence of S/RP.
M&M: 15 patients with at least 4 non-adjacent untreated pockets > 6mm had OHI and S/RP on teeth not participating in the study (NO SRP on treated teeth). Then, sites were assigned to different groups for irrigation with 150ml CHX, TCN 10mg/ml (TCN10), TCN 50 mg/ml (TCN50) or saline solution. Prior to treatment, subgingival paper points were placed to analyze subgingival plaque. Continuous, subgingival irrigation done with a Water Pik for 5 minutes. Post-irrigation was supported by rinsing with CHX b.i.d. 12 week-observation period. PI, GI, PPD, CAL, BOP and microbial morphotypes evaluated pre-op and at 1,2,4,6,8,10,12 weeks.
R: PI decreased from pre to post irrigation and maintained low levels throughout the study. NSSD in PI between groups. GI decreased and difference was SS between saline and other groups at 10 weeks. BOP showed a marked reduction in all groups and TCN50 showed a significant decrease compared to other groups from week 8 up. A significant decreased in PPD observed in all groups, higher for TCN50 (Started with a range of 6.5-7mm, and all groups finished with PPD from 0.8-1.7mm average). CAL changes were minimal for all groups, except for TCN50 that appeared SSD at weeks 10-12 (1.3-1.5mm gain). Phase contrast microscopy of subgingival plaque: Spirochetes and motile rods were markedly decreased for all groups, but SSD was found only for TCN50 group.. Cocci increased for all groups.
BL: A single 5 minutes subgingival irrigation with TCN 50 mg/ml has a significant effect and alters subgingival microbiota towards one associated with health. Author suggests its adjunctive role in supporting conventional treatment in non-responding sites or acute management of systemically compromised patients.
Comment: Supragingival plaque removal prior to irrigation. Rinsing bid with CHX might affect the results.
Mazza 1981 ARTICLE
Purpose: To assess the antimicrobial effect of topical stannous fluoride (SnF2) on suspected pathogenic morphotypes of bacterial plaque in chronic periodontal disease.
M&M: Male patients over 30 years of age who had advanced periodontal diseases (at least 4 teeth with interproximal PDs of 6 mm or more) and had at least two teeth in a relative state of health (PD 4 mm or less and no evidence of vertical bone loss) were included. PI, Periodontal disease index, and bleeding index were measured. At each appointment, plaque samples were collected and immediately viewed under darkfield photomicroscope. Diseased sites received direct subgingival irrigation with 1.64% SnF2, 0.4% SnF2, or sterile physiologic saline. The healthy control site received sterile physiologic saline. Pt. Returned for 2, 4, 7 days and then every week for 9 weeks for plaque sample collection and clinical index measurements.
Results: - 1.64% SnF2 caused a dramatic and sustained decrease of subgingival motile bacteria and spirochetes following irrigation. By the sixth week these bacteria returned to 50% of their original concentration. Bleeding index scores, which were significantly reduced, correlated positively to the reduction in motile bacteria and spirochetes.
- 0.4% SnF2 also demonstrated a similar pattern of reduction of motile bacteria and spirochetes but without their total elimination and a more rapid return to original levels.
- Sterile saline: there was a decrease in motile bacteria, but rapidly returned to baseline levels.
- The healthy control sites were unchanged
- Supragingival plaque index scores did not correlate with the bleeding index, motile bacteria and spirochetes, or with subgingival irrigation.
BL: Stannous Fluoride application may be good to use as an adjunct to periodontal therapy.
Local Drug Delivery
Will you use local delivery systems in your practice? Why? Why not? Under what circumstances?
Hanes 2003 ARTICLE
Purpose: 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 (MEDLINE, the Cochrane Central Trials, Web of Science until April 2002)
M&M: 32 studies included (Randomized controlled clinical trials (RCT), 2 cohort, and 2 case-control), incorporating a total of 3,705 subjects. Inclusion criteria: RCT, case controlled and cohort studies of at least 3 months in pts with a clinical diagnosis of chronic periodontitis. Therapeutic interventions had to include 1) SRP alone 2) local anti-infective drug treatment and SRP 3) local anti-infective drug treatment alone. Exclusion criteria: if they included data from previously published article, Chx daily use, and unclear descriptions of randomization process. Studies had to report: patient based mean values and variation of PD and/or CAL for control and test groups. Secondary outcomes included plaque accumulation, BOP and gingival inflammation.
Results:
Essentially all studies reported substantial reduction in gingival inflammation and bleeding indices (similar in control and experimental group)
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.
Use of antimicrobial irrigates or anti-infective, sustained-release systems as an adjunct to SRP do not result in significant patient-centered adverse events.
Conclusion:
SRP alone can SS reduce PD, BOP and gingival inflammation.
No evidence found for an adjunctive effect on reduction of PD and BOP of therapist-delivered CHX irrigation during SRP compared to SRP alone.
Compared to SRP alone, SRP+ anti-infective agents in sustained release vehicles, SS adjunct on PD reduction or CAL gain and decrease in BOP anticipated. PD reduction= mino gel and microencapsulated MINO; CAL gain= Chx chip and doxy gel
BL: 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 treatment remains a matter of individual clinical judgment, the phase of treatment, and patient status and preferences.
AAP Position Paper 2000 No ARTICLE
Purpose: To review pharmacologic principles which provide the basis for effective local drug delivery (LDD) in treatment of periodontitis and to design a strategy for using local delivery systems in clinical practice
Discussion: Good review on individual drugs used with local delivery systems and how their applications work
Substantivity: ability to bind to soft/hard tissue walls of the pocket, establishing reservoir. Prolongs drug half-life because more is stored in reservoir. In the sub-g environment, tetracycline and clindamycin have demonstrated substantivity.
Clinical efficacy studied using outcome measures: reduced PD, increased CAL, decreased BOP and reduced disease progression
Local drug delivery devices can be divided into 2 classes according to the duration of the medicament release: controlled delivery devices and sustained release devices. Controlled delivery: duration of drug release exceeds 1 day. Sustained release: provide drug delivery for <24 hours
Tetracycline fibers (Actisite):
Non-resorbable cylindrical drug delivery device loaded with 25% tetracycline HCl powder. Completely fill the pocket, cover with cyanoacrylate and leave for 7-10 days. Controlled delivery device: can maintain [GCF] >1300 µg/ml with detectable levels within soft tissue. Salivary concentrations range from 8-51 µg/ml with no detectable serum levels. Unable to completely eliminate bacteria in pocket, but compared to SRP provides similar clinical results. When used adjunctively to SRP, have an additive benefit.
Metronidazole gel (Elyzol):
Not marketed in US at time of review. 25% metronidazole benzoate in a matrix of glyceryl mono-oleate and sesame oil (resorbable) delivered via syringe and cannula. Appears to follow a sustained drug delivery pattern. Can decrease total anaerobic bacteria in sub-g plaque, but only marginal effect. Peak [plasma] observed 2-8 hours via absorption through mucosa or ingestion. Statistically significant but clinically insignificant improvement in clinical parameters when used with SRP.
Minocycline ointment (Dentomycine and Periocline).
Not marketed in US. 2% minocycline HCl in a matrix of hydroxyethyl-cellulose, aminoalkylmethacrylate, triacetine, and glycerine (resorbable). Sustained delivery system (MgCl added to modify drug release). Bacteriostatic. Used adjunctively to SRP, some studies showed significant improvement in PD only of pockets >7 mm, others report no difference.
Chlorhexidine chip (Periochip).
34% chlorhexidine gluconate in a cross-linked gelatin matrix (resorbable). 5mmx5mmx1mm with 2.5 mg of CHX. Controlled delivery system. Detected in GCF at 125µg/ml for 1 week after placement. When placed in 5-8 mm pockets adjunctively to SRP, SS improvement (repeated placement at 3 and 6 months if PD remained >5 mm) in PD and CAL. Defined but limited improvement with chip placement.
Doxycycline polymer (Atridox).
Biodegradable formulation containing 10% by weight doxycycline, 33% by weight poly (DL-lactide) and 57% by wieght N-methyl-2-pyrrolidone. Resorbable. Conflicting data at to efficacy. At this time no data available regarding ability of doxcycline polymer to enhance perio health when used in conjunction with RP; however, potential for disruption of biofilm and removal of calculus prior to local drug delivery may enhance results.
Possible that used of LDD decreases perceived need for surgery. However cannot conclude at this time that local drug delivery actually decreases need for surgery.
Adverse reactions: do not use if known drug allergy. Not enough data to conclude that resistant strains will persist after use. Overgrowth of candida is possible, but should only be used with caution in patients with history of immune deficiency or repeated antibiotic usage. When treating patients with invasive species such as Aa, not enough info to decide if LDD can effectively combat these organisms so systemic antibiotics still recommended.
Greenstein 2006 ARTICLE
P: Review and meta-analysis of local drug delivery systems and their clinical efficacy vs statistical significance.
M+M: Controlled clinical trials were selected that assessed the capability of local drug delivery to improve periodontal health. A search of MEDLINE was conducted up to and including May 2004 using the following strategy: anti-infective therapy in the treatment of periodontitis. A total of 427 papers addressed this subject.
R:
Combined therapy (SRP + LDD) showed a SSD improvement when compared to SRP alone with PD reduction (change of 0.34) but gain of CAL was NSSD.
Doxycycline gel was only one to show a decrease in PD > 2mm as a monotherapy.
For PDs ≥7mm:
NSSD in doxycycline alone or tetracycline fibers alone vs SRP
minocycline w/ SRP vs SRP alone showed greater reduction in PD (1.99 vs 0.98) but found to be NSSD.
Timmerman showed no benefit of minocycline gel w/ SRP in 7mm PD, van Steenberghe showed the combined therapy did demonstrate a benefit when compared to SRP alone.
Doxycycline gel w/ SRP (Machion) and CHX chip w/ SRP (Soskolne) were shown to have better results than SRP alone
In pts w/ ≥5 and ≥ 6mm PDs:
Williams showed SRP w/ minocycline (applied three times: baseline, 3 months, 6 months) had an odds ratio of 1.59 and 2.86 respectively of getting a PD less than 5mm to SRP alone.
Wennstrom showed full mouth debridement w/ doxycycline gel in sites ≥5mm were more likely to become <5mm than w/ SRP alone.
Disease progression:
It is difficult to project outcomes in regard to stopping disease progression due to the limited number of studies have been done, their diverse protocols and different thresholds for disease progression.
Furcations:
Tonetti- tetracycline fibers w/ SRP provided better results than SRP alone up to 6 months, then NSSD after 6 months.
Williams and Meimberg showed a SS greater reduction in molar furcations w/ SRP + minocycline compared to SRP alone.
Osseous defects: other treatment should be considered
To apply LDD during active or maintenance:
Studies have shown an advantage to using LDD in combination w/ initial therapy however the changes between test and control groups tend to be in tenths of mm.
Pts respond to conventional tx so routine chemotherapy during active disease may not be advantageous. However, a number of studies have shown a benefit to using LDD in maintenance pts who did not respond to SRP alone.
BL: Clinicians should select appropriate therapy based on reasonable interpretation of clinical data with regard to management of specific sites and pts, and clinical experience.
PerioChip
Jeffcoat 1998 NO ARTICLE
B: A biodegradable chip (Periochip) for the controlled delivery of CHX directly to the perio pocket has been developed. Its present formulation biodegrades and releases CHX within the pocket over 7-10 days, maintaining an average concentration of CHX in the GCF greater than 125micrograms/mL for 8 days (personal communication from W.A. Soskolne).
P: To evaluate the efficacy of a controlled-release biodegradable CHX (2.5mg) chip when used as an adjunct to scaling and root planing on reducing PD and CAL in adult periodontitis.
M&M: Double-blind, randomized, placebo-controlled multi-center clinical trials were conducted and data was pooled. Pts had a minimum of 10 natural teeth with perio dz characterized by PD of 5-8mm, and having BOP. Smokers and non-smokers included. At baseline, after 1 hour of SRP in pts without supra-g calculus (removed prior to study if necessary), the chip was placed into sites with PDs of 5-8mm with BOP. Each pt had 2 test sites (SRP + Perio Chip) and 2 control sites (SRP alone + placebo chip). Sites that received SRP alone also served as control sites. Chip placement (active or placebo) was repeated at 3 and/or 6 months if PD remained 5mm. Study sites in active chip subjects either received placebo chip + SRP or SRP alone. Exams (PD, CAL, BOP, GI, PI, Straining) performed at baseline, 1 wk, 6 wks, 3, 6, and 9 months.
R: 211 active chips and 208 placebo chips completed the trial. The % of perio pockets that had a reduction of 2mm or more increased in the active CHX chip group from 7% at 6 weeks to 19% at 9 months. The SRP alone group went from 9.4% at 6 weeks to 8% at 9 months and for placebo chip from 8% at 6 weeks to 13% at 9 months. The differences were SS between the active chip group vs. the two control groups. There were no clinically significant changes in GI, PI, or staining index during the study. Toothache (included: dental, gingival, or mouth pain: aching, throbbing soreness, discomfort, sensitivity) was higher for the active chip group compared to the placebo. Most adverse events were minor, not serious in nature, and were of short duration. No serious adverse events were reported.
BL: The CHX chip is an effective adjunct to SRP. The difference is significant in 12% more sites than performing SRP alone.
Jeffcoat 2000 ARTICLE
Purpose: To determine if the CHX chip was effective in maintaining alveolar bone over a 9-month period in subjects from a parent study.
Materials and methods: 9-month controlled clinical trial, studies 45 patients with periodontitis
Mechanical therapy and OHI were performed and at baseline, each patient had 4 study sites with PD (to the nearest 0.5 mm) 5 to 8 mm with BOP. Control groups received either placebo chip + SRP or SRP alone. Test groups received active CHX chip or SRP alone. Patients returned for charting of PD and CAL at 1, 3, 6, and 9 months. Placebo or CHX chips were replaced at 3 and 6 months in sites with PD > 5 mm. Standardized radiographs were taken at baseline and at 9 months.
Results: 42 patients completed the study. At 9 months, mean reduction in PD was 0.85 - 0.12 mm for CHX chip +SRP group , 0.47 - 0.11 mm for SRP group alone, and 0.29 - 0.13 mm for the SRP plus placebo group. There was a significant difference between the CHX chip + SRP group and the other groups. CAL change after 9 months was 0.92 - 0.17 mm in CHX chip + SRP, and was 0.38 - 0.14 mm for SRP + placebo chip (significant). Digital subtraction radiography revealed 15% of SRP sites and 11% of SRP + placebo chip sites had bone loss, while 25% of the sites in the CHX chip group showed 0.1mm bone gain.
Conclusion: Control of subgingival micorflora by both mechanical and chemotherapeutic approaches may control clinical attachment loss and bone loss associated with progressive periodontitis. (PD and CAL reduction was about 0.4mm compared to the control groups)
Arestin
Grossi 2007 ARTICLE
Purpose: To examine the antimicrobial and clinical effects of SCRP with and w/out minocycline HCL 1mg microspheres (MM) relative to smoking status in subjects with p dz/
Materials and methods
127 subj. (46 never smokers, 44 former smokers, 37 current smokers) with moderate to advanced pdz were randomized to receive MM and SCRP (62) or SCRP alone (65).
Sub-g plaque samples collected at baseline and at day 30 and were examined for presence of 40 perio bacteria by DNA probe analysis.
Results
MM + SCRP reduced red complex bacteria (RCB) numbers and proportions to a greater extent than SCRP alone, irrespective of smoking status.
RCB numbers were not reduced by SCRP in current smokers.
The difference in the reduction in numbers of RCB by SRP relative to MM + SRP in current smokers was statistically significant (P <0.05).
Numbers and proportions of orange complex bacteria (OCB) were reduced in all groups treated with MM + SRP.
Proportions of OCB increased in current smokers treated with SRP alone.
BL: In current smokers, MM + SRP significantly reduced PD, increased CAL gain, and reduced BOP to a greater extent than SRP alone.
Cortellini 2006 ARTICLE
P: To evaluate the clinical response to scaling and root planning combined with the use of locally delivered minocycline microspheres in individuals with advanced chronic periodontitis during 720-day treatment protocol.
M&M: 26 patients (12 females and 14 males), aged 26-69 years, with non-treated chronic periodontitis, non-smokers and in good general health participated in the study. Two homologous sites (no molars, no furcation involvement) with PD >= 6mm were selected from each patient to evaluate the clinical response to SRP combine with the use of subgingival minocycline (SM). Two groups were formed: Test group (SRP+SM) that received local delivery of minocycline at baseline and 90,180, 270 days and control group (SRP +vehicle) that received a placebo at the same timepoints. PD, plaque index (PI), and gingival index (GI) were assessed at baseline and 90, 180, 270, 360 and 720 days.
R: In both groups, mean PD values showed statistically significant reductions between baseline and 90 days. There were no differences at 180, 270 and 360 days. However, there was a significant increase at 720 days for both groups. When PD values were compared, there was a bigger reduction in the test group at 270 and 360 days. No statistical differences were observed at 90,180 and 720 days between test and control groups.
PI and GI demonstrated statistically significant reductions from baseline to 90 days in both groups. Longitudinal evaluation showed that PI and GI remained reduced from 90-360 days, but both indices increased at 720 days. No statistically significant differences in PI and GI were observed between test and control groups at baseline and 90, 180, 270, 360, and 720 days.
C: Both therapies reduced mean PD from 90 to 360 days. However, SRP+SM showed a higher reduction at 270 and 360 days following therapy.
Renvert 2006 ARTICLE
P: To study the clinical and microbiological results during a period of 12 months after application of minocycline microspheres (Arestin) as an adjunct to mechanical treatment of incipient peri-implant infections compared with an adjunctive treatment using 1% chlorhexidine gel application.
M&M: 32 subjects, 41-75 years old who had peri-implantitis sites with probing depth greater than or equal to 4 mm, combined with bleeding and/or exudate on probing and presence of putative pathogenic bacteria. Subjects were given oral hygiene instructions and mechanical treatment of infected areas adjacent to implants. The subjects were randomly assigned adjunctive subgingival antimicrobial treatment using either chlorhexidine gel or minocycline microspheres. 16 patients in the minocycline group and 14 in the chlorhexidine group completed the study. Follow-up examinations were carried out after 10 days, 1, 2, 3, 6, 9 and 12 months.
R:
The adjunctive use of minocycline microspheres (Arestin) resulted in improvements of PDs and bleeding scores, while adjunctive use of chlorhexidine only resulted in limited reduction of bleeding scores. For deepest sites of the treated implants in the minocycline group, the mean probing depth was reduced from 5.0mm to 4.4 mm at 12 months. This study could not show any significant difference in the levels of bacterial species or groups at any time point between the two antimicrobial agents tested.
BL: The use of a local antibiotic as an adjunct to mechanical treatment of incipient peri-implantitis lesions demonstrated improvements in probing depths that were sustained over 12 months.
Oringer 2002 ARTICLE
Purpose: To evaluate the efficacy of the local administration of 1 mg minocycline microspheres (Arestin) in periodontal pockets of ≥ 5 mm in smokers.
M & M: A multi-center clinical trial; a combination of 3 studies. 18 centers, 271 were smokers and were included in the two single blind controlled studies with efficacy of the combination therapy of Arestin+SRP compared to SRP alone. 71 smokers were enrolled in an open label study. PD reduction at 9 months was used as the primary outcome in all three studies. SRP was performed at baseline and pt. was stratified in 3groups- SRP alone, SRP+placebo and SRP+Arestin. The unit dose minocycline administered at baseline, three and six months. Efficacy and safety were measured at one, three, six, and nine months in all studies.
Results: Average PD reduction (mm) at 1 and 9 months in smokers
| At one months | At 9 months | ||
| Single blind study | Open level study | Single blind study | Open level study |
| SRP SRP+Arestin | SRP+Arestin | SRP+Aresin | SRP+Arestin |
| 0.92 1.11 | 1.26 | 1.19 | 1.60 |
Adjunctive treatment resulted in SS PD reduction and AL gain in both studies in smokers. In the controlled studies the difference in PD reduction between the adjunctive therapy group and the SRP alone group was SS (0.29mm) at 9 months. No serious adverse events were recorded in any of the studies.
BL: Arestin as an adjunct to SRP is more effective in reducing PD than SRP alone in smokers with chronic periodontitis.
Host Modulation with Sub-Antimicrobial Dose of Doxycycline (Periostat, Collagenex)
Preshaw 2005 ARTICLE
P: Previously reported studies of the adjunctive use of SDD in the treatment of periodontitis did not report treatment outcomes by smoking status. So, the aim of this study is to investigate retrospectively the efficacy of SDD as an adjunct to SRP in the treatment of smokers and non-smokers with moderate-severe chronic periodontitis.
M&M: A meta-analysis of the outcomes of two previously reported clinical studies. Both studies evaluated the efficacy of SDD (20mg doxycycline twice daily) in combination with SRP in subjects with moderate-severe CP. All subjects underwent SRP and were randomly allocated to receive either adjunctive SDD or adjunctive placebo for 9 months. Subjects were evaluated 3, 6 and 9 months after baseline, at which time points full-mouth clinical indices were recorded. In the meta-analysis, patient data from both studies were combined in a single analysis. 36.9% of the combined study population was smokers. 392 subjects were included in the meta-analysis. The change in PD and CAL from baseline and the total number of sites with attachment gains and PD reductions >=2 and >=3mm from baseline in four subgroups : smokers/SDD, smokers/placebo, non-smokers/SDD, non-smokers-placebo were evaluated.
R: Non-smokers that received SDD demonstrated the greatest CAL gains and PD reductions. Smokers who received placebo demonstrated the smallest clinical improvements following treatment. In sites with baseline PD 4-6mm month 9 mean CAL gains were significantly greater in non-smokers who received SDD than in other subgroups. Month 9 CAL gains from baseline in smokers who received SDD were 21% greater than smokers who received placebo. In sites with baseline 4-6mm, month 9 mean PD reductions were significantly greater (21-53%) in non-smokers who received SDD than in all other subgroups. Month 9 PD reductions from baseline in smokers who received SDD were 26% greater than smokers that received placebo.
C: This meta-analysis demonstrated the benefits of adjunctive SDD in both smokers and non-smokers. Non-smokers who received SDD demonstrated the best treatment response and smokers who received placebo demonstrated the poorest treatment response. Outcomes following treatment were broadly similar in smokers who received SDD and non-smokers that received placebo.
Novak 2008 ARTICLE
P: To test the hypothesis that a combination of systemically administered host modulating therapy (HMT) and topical antimicrobial therapy (TAT), as adjuncts to SRP, would provide significantly improved clinical benefits in the treatment of moderate to severe chronic periodontitis compared to SRP alone.
M&M: A 6 month, randomized, multicenter, placebo controlled, examiner masked study. The study conducted at 6 dental schools in 171 subjects (24-71 years old). Each subject needed at least eight qualifying tooth sites on a minimum of three teeth in at least two quadrants with previously untreated chronic periodontitis; six of the eight sites needed PD equal or greater than 5 mm, and two of the eight sites needed PD equal to or greater than 7 mm and clinical attachment loss (CAL) equal to or greater than 5 mm. Each site had to demonstrate positive BOP and GI equal to or greater than 1.
All subjects received full mouth SRP at baseline and at 3 months. Experimental group (88 subjects) received systemically delivered doxycycline hyclate (HMT 20 mg) twice a day plus locally delivered doxycyline hyclate gel (TAT 10%) in pockets equal to or greater than 5 mm in combination with SRP versus SRP plus placebo. Control group (83 subjects) received systemically administered placebo 2 times a day. Clinical measures (PD, CAL, BOP and GI) were assessed at baseline, 3 and 6 months.
R: No SD between the two groups for age, gender or tobacco use. Combination therapy provided significantly greater clinical benefit than control group for all clinical measures at 3 and 6 months.
PD 4-6MM PD>7mm
| PD reduction | CAL gain |
BOP reduction |
PD reduction |
CAL gain |
BOP reduction |
|
TEST (6 months) |
1.7mm |
1.5mm |
43% |
2.4mm |
2.2mm |
29% |
CONTROL (6 months) |
1.2mm |
1.2mm |
32% |
1.7mm |
1.6mm |
19% |
BL: Combination therapy including SRP, HMT and TAT provide significantly greater benefits than SRP alone in the treatment of moderate to severe chronic periodontitis.