Clinical and microbiological effects of initial periodontal therapy in conjunction with amoxicillin and clavulanic acid in patients with adult periodontitis

The aim of the present study was to investigate the clinical and microbiological effects of initial periodontal therapy in conjunction with systemic amoxicillin plus clavulanic acid in adult periodontitis patients using a double-blind, parallel-group, and placebo-controlled protocol. 21 patients with a clinical diagnosis of generalised adult periodontitis were recruited. Clinical measurements and microbiological assessments were carried out at baseline, 3, and 12 months post-treatment. Approximately 6 weeks after initial periodontal treatment (3-6 h), patients were randomly assigned to receive coded study medication of 500 mg amoxicillin plus 125 mg clavulanic acid (Augmentin) or placebo, every 8 h for 10 days. Patients returned for follow-up visits 3, 6, 9, and 12 months after completion of the medication. The mean plaque index (PI) at baseline was 1.1 for placebo group and 0.9 for the test group. At 3 months, the PI had dropped to 0.3 in both groups, and was maintained during the rest of the study. The changes in bleeding on probing (BOP) and gingival index (GI) in the course of the study were similar in both groups. The mean whole mouth probing pocket depth (PPD) in the placebo group was 3.8 mm at baseline and 3.9 mm in the test group. A mean reduction of 1.0 mm in the placebo group and 0.9 mm in the test group was observed during the first 3 months. No further reduction in PPD was noticed during the study period in either group. There was no statistically significant difference in the PPD reduction between the 2 groups. The change in clinical attachment level (CAL) from baseline to 3 months amounted to 0.5 mm in both groups. Between 3 and 12 months, the CAL changed in neither group. In both groups, treatment resulted in a decrease in the number of spirochetes and motile rods in positive patients, but no significant differences between either group were noted in any of the dark field microscopy observations. At baseline, 1 patient in the placebo group and 2 patients in the test group were culture positive for Actinobacillus actinomycetemcomitans (Aa). After therapy, Aa was not detectable in the placebo group and 1 patient remained positive in the test group. In the placebo group, the number of patients positive for Porphyromonas gingivalis (Pg) decreased from 7 to 2 after therapy. In the test group, the 4 patients positive for Pg at baseline remained positive after therapy. In both groups, all subjects were positive for Prevotella intermedia (Pi) and Fusobacterium nucleatum (Fn) at baseline. At 12 months, all subjects had detectable subgingival Fn. 9 out of the 11 placebo and 8 of the 10 test patients remained positive for Pi. There were no differences in detection frequency of Peptostreptococcus micros (Pm) and Bacteroides forsythus (Bf) in both groups between baseline, 3, and 12 months post-treatment. The findings demonstrated that, in comparison to placebo, systemic amoxicillin plus clavulanic acid provided no additional clinical and microbiological effects in the treatment of adult periodontitis patients.     

Metronidazole in the treatment of refractory periodontitis

In this article the clinical and microbiological effects of systemic metronidazole in the treatment of refractory periodontitis in adult patients is discussed. For this study, 27 adult patients with detectable Bacteroides forsythus and culture negative for Actinobacillus actinomycetemcomitans were selected. After renewed supra- and subgingival debridement, patients were treated with systemic metronidazole (500 mg TID) for 7 days. Mean probing pocket depth, probing attachment level and bleeding index significantly improved after metronidazole therapy. Patients that became culture negative for B. forsythus showed a significant better therapy response in comparison to subjects that had detectable B. forsythus post-therapy. The maximum clinical response was observed in patients that became negative for B. forsythus, Porphyromonas gingivalis and Prevotella intermedia after renewed debridement and metronidazole therapy. It is concluded that systemic metronidazole therapy can be effective in refractory adult periodontitis. Microbiological analyses of the subgingival microflora in these patients can assist in selecting patients that may benefit from systemic metronidazole therapy.     

Microbiological and clinical results of metronidazole plus amoxicillin therapy in Actinobacillus actinomycetemcomitans-associated periodontitis.

We report on the microbiological and clinical effects of mechanical debridement in combination with metronidazole plus amoxicillin therapy in 118 patients with Actinobacillus actinomycetemcomitans-associated periodontitis. Patients were categorized into 3 groups: 28 had localized periodontitis; 50 had generalized periodontitis, and 40 had refractory periodontitis. After initial treatment and metronidazole plus amoxicillin therapy 114 of 118 (96.6%) patients had no detectable A. actinomycetemcomitans. Significant reduction in pocket probing depth and gain of clinical attachment were achieved in almost all patients. Four patients were still positive for A. actinomycetemcomitans after therapy. Metronidazole resistance (MIC greater than 25 micrograms/ml) was observed in 2 of 4 strains from these patients. Patients still positive for A. actinomycetemcomitans or Porphyromonas gingivalis showed a significant higher bleeding tendency after therapy. It was concluded that mechanical periodontal treatment in combination with the metronidazole plus amoxicillin therapy is effective for subgingival suppression of A. actinomycetemcomitans in patients with severe periodontitis.     

Clinical and microbiological effects of different antimicrobials on generalized aggressive periodontitis

AIM: To evaluate and compare the effects of adjunctive metronidazole plus amoxicillin, doxycycline and metronidazole on clinical and microbiological parameters in patients with generalized aggressive periodontitis. MATERIAL AND METHODS: Forty-three patients participated in this randomized clinical trial divided into four groups. Six weeks after scaling and root planning (SRP), groups 1-3 received adjunctive metronidazole, plus amoxicillin, doxycycline and metronidazole respectively, and group 4 acted as controls. Clinical recordings concerning probing depth, probing attachment level and bleeding on probing were performed at baseline, 6 weeks after SRP and 6 months from baseline. Subgingival samples were analysed using the 'checkerboard' DNA-DNA hybridization for Porphyromonas gingivalis, Actinobacillus actinomycetemcomitans, Tannerella forsythia and Treponema denticola. Results: All treatments resulted in improvement of clinical parameters (ANOVA p > 0.05). Systemic administration of metronidazole plus amoxicillin or metronidazole resulted in statistically significant greater reduction of the proportion of sites > 6 mm than SRP (z-test, p < 0.05). These antimicrobials yielded a significant effect on levels of important periodontal pathogens for 6 months. CONCLUSION: Adjunctive metronidazole plus amoxicillin or metronidazole alone (when A.actinomycetemcomitans is not involved) is effective in deep pockets of aggressive periodontitis patients.     

Adjunctive effects of systemic amoxicillin and metronidazole with scaling and root planing: a randomized, placebo controlled clinical trial

AIMS: The objective of this study was to investigate the effect of the systemic administration of metronidazole and amoxicillin as an adjunct to initial periodontal therapy in patients with moderate to severe chronic periodontitis. METHODS AND MATERIALS: This randomized, double blind, placebo controlled parallel study involved 50 adult patients with untreated periodontitis who were randomly assigned to receive either a full-mouth scaling and root planing along with systemic metronidazole and amoxicillin (T group) or scaling and root planing with a placebo (P group). Clinical measurements including probing depth (PD), clinical attachment levels (CAL), Plaque Index (PI), and Bleeding Index (BI) were recorded at baseline and six to eight weeks after therapy. The deepest pocket was selected and samples for microbiological testing were taken. Patients received coded study medications of either 500 mg amoxicillin in combination with 250 mg metronidazole or an identical placebo every eight hours for seven days following scaling and root planing. RESULTS: There was a significant change in PD (P=0.0001), CAL (P=0.00001), PI (P<0.05), and BI (P<0.05) in the T group compared to the placebo group after therapy. Parallel to the clinical changes, treatment significantly reduced the number of Actinobacillus actinomycetemcomitans (Aa), Porphyromonas gingivalis (Pg), and P. intermedia (Pi) compared with baseline in the T group (P=0.003, 0.021 and 0.0001, respectively). However, in the P group only the Pi colony count was reduced significantly (P=0.0001). After therapy, there was a significant difference between the T and P groups in the number of patients negative for Aa, Pg, and Pi (Pv = 0.033). CONCLUSIONS: The significant differences between treatment and placebo groups are in line with other studies and support the considerable adjunctive benefits of the combination of amoxicillin and metronidazole in the treatment of chronic periodontitis.     

Adjunctive benefits of systemic amoxicillin and metronidazole in non-surgical treatment of generalized aggressive periodontitis: a randomized placebo-controlled clinical trial

BACKGROUND: The objective of this study was to assess the adjunctive clinical effect of the administration of systemic amoxicillin and metronidazole in the non-surgical treatment of generalized aggressive periodontitis (GAP). METHODS: Forty-one systemically healthy subjects with GAP were included in this 6-month double-blind, placebo-controlled, randomized clinical trial. Patients received a course of full-mouth non-surgical periodontal treatment delivered over a 24 h period using machine-driven and hand instruments. Test subjects received an adjunctive course of systemic antibiotic consisting of 500 mg amoxicillin and 500 mg metronidazole three times a day for 7 days. Clinical parameters were collected at baseline, and at 2 and 6 months post-treatment. RESULTS: In both the test and the placebo groups, all clinical parameters improved at 2 and 6 months. In deep pockets (> or =7 mm), the test treatment resulted in an additional 1.4 mm (95% confidence interval 0.8, 2.0 mm) in full-mouth probing pocket depth (PPD) reduction and 1 mm (0.7, 1.3 mm) of life cumulative attachment loss (LCAL) gain at 6 months. In moderate pockets (4-6 mm), the adjunctive benefit was smaller in magnitude: PPD reduction was 0.4 mm (0.1, 0.7 mm) and LCAL gain was 0.5 mm (0.2, 0.8 mm). In addition, the 6-month data showed LCAL gains > or =2 mm at 25% of sites in test patients compared with 16% in placebo (p=0.028). Similarly, PPD reductions of 2 mm or more were observed in 30% of sites in test and 21% of sites in placebo patients. Seventy-four percent of pockets with PPD > or =5 mm at baseline were 4 mm or shallower at 6 months in the test group. This compared with 54% in the placebo group (p=0.008). Disease progression at 6 months was observed at 1.5% of test and 3.3% of sites in test and placebo, respectively (p=0.072). CONCLUSIONS: These data indicate that a 7-day adjunctive course of systemic metronidazole and amoxicillin significantly improved the short-term clinical outcomes of full-mouth non-surgical periodontal debridement in subjects with GAP.     

Effects of metronidazole in patients with "refractory" periodontitis associated with Bacteroides forsythus

Abstract The aim of the present study was to monitor the microbiological and clinical effects of renewed supra and sub gingival debridement in conjunction with systemic metronidazole therapy (500 mg TID for 7 days) in 27 “refractory” periodontitis patients, culture positive for Bacteroides forsythus and negative for Actinobacillus actinomycetemcomitans. Clinical evaluation included assessment of plaque, bleeding upon probing, probing pocket depth and clinical attachment loss at the deepest, bleeding site in each quadrant. Microbiological evaluation was carried out by anaerobic cultivation of sub gingival plaque samples from the same sites. 6 months after renewed debridement and systemic metronidazole (RD + M). a statistically significant improvement of all clinical parameters was observed, except for the plaque index. After RD + M, B. forsythus was suppressed below detection level in 17 of the 27 patients, P. gingivalis in 9 out of 15 patients and P. intermedia in 14 of the 21 patients. Before RD+M. 12 patients harboured simultaneously B. forsythus, P. gingivalis as well as P. intermedia. Out of these 6 patients were culture negative for the 3 species after therapy and showed the greatest reduction in pocket depth (3.1 mm) and gain of clinical attachment level (2.5 mm). In the treatment of refractory periodontitis. associated with patients culture positive for B. forsythus and negative for A. actinomycetemcomitans, metronidazole can significantly improve the clinical and microbiological parameters.     

Combined effects of Nd:YAG laser irradiation with local antibiotic application into periodontal pockets

The purpose of the present study was to assess the effects of Nd:YAG laser irradiation into periodontal pockets with or without the combination of local antibiotic application on clinical parameters and microbiological prevalence. Sixteen patients, each of whom had 4 or more sites with probing depth e x 4mm were included in this study. They were monitored clinically and microbiologically at baseline, 1 and 3 months after the treatment. Subgingival plaque samples were taken from periodontally involved sites with a probing depth of e x 4mm. A total of 135 sites were randomly assigned to the following treatments; Nd:YAG laser alone (Group L: 10 pps, 200 mJ for 90 sec, n = 37), local minocycline administration following laser treatment (Group LP, n = 33), povidone-iodine irrigation following laser treatment (Group LI, n = 33), and control group (Group C: sham procedure, n = 32). The prevalence of 18 subgingival taxa were determined using the checkerboard technique. The mean value of the pocket probing depth (PPD) significantly decreased in Group L, Group LP and Group LI, and the mean clinical attachment loss (CAL) decreased in all three treatment groups. Multivariate logistic regression analysis showed that Group LP showed the most improvement in PPD or CAL at 3 months. The proportions of Porphyromonas gingivalis, Tannerella forsythia (formerly Bacteroides forsythus) and Prevotella intermedia were significantly lower in Group LP than in Group L after 3 months. These results showed that Nd:YAG laser irradiation plus local minocycline provides a much greater reduction in PPD, CAL and the amount of periodontopathogenic bacteria than laser irradiation alone in periodontitis patients.     

Effect of initial periodontal therapy on the frequency of detecting Bacteroides forsythus, Porphyromonas gingivalis, and Actinobacillus actinomycetemcomitans.

BACKGROUND: Porphyromonas gingivalis, Bacteroides forsythus, and Actinobacillus actinomycetemcomitans have been described as periodontopathic bacteria, and their presence in subgingival pockets can lead to development of periodontal disease. Until now, clinical parameters have been used to evaluate the effect of conventional periodontal treatment without microbiological parameters. The present study examined the microbiological effects of initial periodontal therapy using DNA probes and the polymerase chain reaction (PCR). METHODS: Twenty-six patients with periodontitis, 10 males and 16 females, were given instructions regarding oral hygiene, then thoroughly treated by conventional scaling and root planing. Bacterial samples were collected on paper points from 4 sites per patient at baseline and after initial therapy (total: 104 sites). Clinical parameters including probing depth, attachment level, and bleeding on probing were also recorded for each site at baseline and after therapy. A DNA probe kit was used to monitor the frequency of B. forsythus, P. gingivalis, and A. actinomycetemcomitans, the last of which was identified by PCR. RESULTS: At baseline, B. forsythus was the bacterium most frequently detected. DNA probe analysis also showed that more than half of the sites were colonized by both B. forsythus and P. gingivalis. Initial therapy resulted in significant clinical improvement such as significant reduction in the frequency of B. forsythus and P. gingivalis detected using the DNA probe. A. actinomycetemcomitans was difficult to detect using the DNA probe, but PCR indicated that levels of A. actinomycetemcomitans did not significantly decrease. CONCLUSIONS: These results indicate that initial conventional therapy can eliminate B. forsythus and P. gingivalis, but not A. actinomycetemcomitans. When levels of these bacteria decreased to below-detectable levels, clinical improvement was significant. These results indicate that monitoring levels of these three periodontopathic bacteria may render periodontal therapy more effective and accurate.     

Incomplete adherence to an adjunctive systemic antibiotic regimen decreases clinical outcomes in generalized aggressive periodontitis patients: a pilot retrospective study

AIM: The objective of this study was to explore the effect of incomplete adherence to the prescribed antibiotic regimen, amoxicillin and metronidazole, in the non-surgical treatment of generalized aggressive periodontitis (GAP). METHODS: This retrospective study included 18 GAP subjects who received a conventional course of full-mouth non-surgical periodontal treatment using machine-driven and hand instruments and an adjunctive course of systemic antibiotics (500 mg amoxicillin and 500 mg metronidazole three times a day for 7 days). Clinical parameters were collected at baseline and at 2 months post-treatment. Self-reported adherence to the prescribed medication regimen was recorded at 2 months. RESULTS: All clinical parameters, except for the mean clinical attachment level (CAL) in sites with initial probing pocket depth (PPD) < or = 3 mm, improved at 2 months in all subjects. PPD reduction was 3.7 mm [95% confidence interval (CI) 3.2, 4.3 mm] in deep pockets (> or = 7 mm) and 2.2 mm (95% CI 1.9, 2.4 mm) in moderate pockets (4-6 mm), while CAL gain was 2.2 mm (95% CI 1.7, 2.6 mm) and 1.2 mm (95% CI 0.8, 1.5 mm), respectively. However, only 11 subjects (61.1%) reported full adherence to the medication. In deep pockets (> or = 7 mm), the difference between an adherent and non-adherent/partially adherent subject was 0.9 mm (95% CI 0.1, 1.7 mm, ancova, p=0.027) in PPD reduction and 0.8 mm (95% CI -0.2, 1.9, p=0.129) in CAL gain at 2 months. In moderate pockets (4-6 mm) this difference was smaller in magnitude: 0.4 mm (95% CI 0.1, 0.9 mm, p=0.036) in PPD reduction and 0.2 mm (95% CI -0.3, 0.9 mm, p=0.332) in CAL gain. CONCLUSIONS: Within the limits of this design, these data suggest that incomplete adherence to a 7-day adjunctive course of systemic metronidazole and amoxicillin is associated with decreased clinical outcomes in subjects with generalized aggressive periodontitis.     

Five-year maintenance follow-up of early-onset periodontitis patients

OBJECTIVES: The purpose of this study was to evaluate the clinical and microbiological status of patients with early-onset or aggressive periodontitis (EOP) who had received supportive periodontal care (SPC) every 3-6 months for a period of 5 years, following active periodontal treatment. MATERIAL AND METHODS: The study population consisted of 25 individuals with early-onset periodontitis. Clinical examination and recordings of probing pocket depth (PPD) and clinical attachment level (CAL) were performed at baseline prior to treatment (T0), 3 months following the termination of active periodontal treatment (T1) and annually at the SPC appointments (T2,T3,T4,T5). Microbiological samples were obtained at the 5-year SPC (T5). Subgingival plaque samples for each individual were collected from one deep pocket (>5 mm), based on pretreatment measurements, randomly selected in each quadrant. The levels of Actinobacillus actinomycetemcomitans, Bacteroides forsythus, Porphyromonas gingivalis and Treponema denticola were determined using oligonucleotide probe hybridization. RESULTS: During the 5-year period, the mean of SPC/patient was 12.7 sessions. A significant improvement was observed in PPD, CAL, gingival bleeding index and suppuration following treatment. However, between T1 and T5, 134 sites in 20 patients deteriorated with a CAL loss of> or =2 mm. Out of these 134 sites showing disease progression, microbial samples were randomly obtained in 13 sites (9.7%) from 8 patients. Among other factors, smoking and stress were found to have significant predictive value on the future attachment loss. P. gingivalis, T. denticola and total bacterial load were statistically significantly higher in patients who experienced disease progression during the 5-year maintenance period. CONCLUSIONS: For most EOP patients, regular SPC was effective in maintaining clinical and microbiological improvements attained after active periodontal therapy. However, a small percentage of sites was identified as progressive in 20 patients. Variables found to be related to periodontal progression were the presence of as well as the high bacterial counts of P. gingivalis, T. denticola and total bacterial load, number of acute episodes, number of teeth lost, smoking and stress.     

Metronidazole in periodontitis. I. Clinical and bacteriological results after 15 to 30 weeks

The statistical association of certain anaerobic organisms such as black pigmented bacteroides (BPB) species and spirochetes with clinical signs of active periodontitis, i.e. bleeding upon probing and bone loss, suggests that the lesions may actually reflect a "specific infection" involving these or unidentified species. All the known oral species of BPB and spirochetes are anaerobes which suggests that antimicrobial treatment directed specifically against anaerobes might be effective in periodontal therapy. In this report, the short-term results of metronidazole treatment plus mechanical debridement in patients with extensive periodontal disease and of a double-blind clinical study in which metronidazole plus mechanical debridement is compared to placebo plus mechanical debridement are described. The findings indicate that 1 week of systemic metronidazole can optimize the clinical reduction of pockets and increase the apparent attachment in periodontitis patients who receive concurrent mechanical debridement of their root surfaces. In patients with extensive clinical involvement, metronidazole resulted in a significant reduction in the number of sites exhibiting pocket depths and attachment loss greater than or equal to 7 mm. When metronidazole plus mechanical debridement was compared with placebo plus mechanical debridement in a double-blind study, the metronidazole patients exhibited a significant improvement in those sites initially greater than or equal to 7 mm. The beneficial effect of the metronidazole was associated with a significant and sustained reduction of certain anaerobic organisms such as Bacteroides gingivalis and the large spirochetes. These data indicate that treatment aimed specifically toward the anaerobic component of the plaque flora can be associated with impressive clinical improvements 15 to 30 weeks after the initiation of treatment.     

Repeated local metronidazole-therapy as adjunct to scaling and root planing in maintenance patients

The purpose of this investigation was to evaluate the effect of local antibiotic therapy with metronidazole adjunctively to scaling and root planing (SRP) versus mechanical treatment alone. 30 maintenance-patients were included in this single-blind study. The subjects had to comply with the following criteria: 2 non-adjacent sites with a probing depth > or =6 mm with bleeding on probing in separate quadrants, no periodontal therapy within the last 3 months, and no antibiotic therapy within the last 6 months. After randomization, the study sites were assigned to one of the following 2 treatments: SRP plus subgingival application of metronidazole 25% dental gel (Elyzol) 5x during 10 days (test site) or SRP alone (control site). Subgingival microbiological samples were taken prior to, and 21 days and 3 months after scaling. The samples were analyzed with a commercial chair-side ELISA (Evalusite) for Porphyromonas gingivalis, Prevotella intermedia and Actinobacillus actinomycetemcomitans. Probing pocket depth (PPD), attachment level (AL) and bleeding on probing (BOP) were recorded at baseline and 3 months later. PPD reduction and AL-gain were statistically significant (p<0.001) after both treatments. However, there were no statistically significant differences between them. The same observation was made for BOP. P. gingivalis was reduced significantly after both treatments without statistically significant differences. P. intermedia was reduced significantly only after SRP. A. actinomycetemcomitans was not reduced significantly after either treatment. In conclusion, the repeated local application of metronidazole as an adjunct to SRP and the mechanical treatment alone showed similar clinical and microbiological effects without statistically significant differences with the exception of P. intermedia.     

Clinical and microbiological effects of topical minocycline in the treatment of elderly patients with periodontitis

OBJECTIVE: To evaluate a 2% w/w minocycline gel (Dentomycin) in the treatment of older adults with chronic periodontitis. DESIGN: Vehicle-controlled, split-mouth SETTING: Dental Institute, St Bartholomew's and the Royal London School of Medicine and Dentistry. SUBJECTS: 22 adults (mean age 60 years). INTERVENTIONS: At baseline, patients received scaling and root planing. Test and placebo were applied at contralateral disease sites surrounding 22 test and 22 control teeth at baseline, and at weeks 2 and 4. MAIN OUTCOME MEASURE: Probing pocket depth, bleeding on probing and supragingival plaque measurements, and microbiological sampling, at one pocket site per tooth were undertaken at baseline, and at weeks 2, 4, 6 and 16. RESULTS: Microbial counts of Porphyromonas gingivalis, Prevotella intermedia and Eikenella corrodens did not change significantly over 16 weeks. No significant reductions in bleeding on probing and supragingival plaque score occurred with either gel. A larger reduction in mean pocket depth, from baseline to week 16, was found at test (6.50 to 4.95 mm; 24% reduction; P < 0.01) than at control sites (6.41 to 5.53 mm; 14% reduction; P < 0.05). CONCLUSIONS: Minocycline gel administration is a useful adjunct to scaling and root planing in the treatment of older adults with periodontitis.     

Clinical effects of pulsed oral irrigation with 0.2% chlorehexidine digluconate in patients with adult periodontitis

The aim of this study was to investigate the effects of using 0.2% Chlorhexidine digluconate in an pulsated jet irrigator by patients as part of their daily dental home-care measures. After initial assessment, 16 patients diagnosed as having adult periodontitis received scaling and polishing together with advice on the subgingival use of a pulsated jet oral irrigator with which they were supplied. 8 patients having 293 active sites with probing depths equal to or in excess of 4 mm used 0.2% chlorhexidine digluconate (CHX) in the oral irrigator, 2 x daily for 56 days. The other group of 8 patients with 253 active sites over 4 mm used a placebo as the irrigating solution. A modified dichotomous plaque index (MPI), gingival bleeding index (GBI) and probing pocket depths (PPD) were assessed on days 0, 28 and 56. Within-group comparisons showed that the CHX regime reduced MPI, GBI and PPD significantly but that the placebo group (PG) only achieved a significant reduction in the PPD. Between-group comparisons showed that the use of 0.2% CHX as an irrigant was significantly more effective than the placebo solution at reducing all the clinical parameters studied. The patients found the oral irrigator easy and pleasant to use, although all the CHX group developed staining to a varying extent. This double blind study demonstrated that 0.2% CHX used 2 x daily in an oral irrigator was effective at reducing plaque deposition, periodontal inflammation and probing pocket depths. The effects of using lower concentrations of chlorhexidine digluconate in this regime need to be investigated.     

Effect of smoking and periodontal treatment on the subgingival microflora

BACKGROUND: The effect of smoking on the prevalence of periodontal pathogens after periodontal treatment is still not clear. Some studies found no effect of the smoking status on the prevalence of periodontal pathogens after therapy, whereas others did. The aim of this retrospective study was to investigate the influence of smoking on the treatment of periodontitis and the composition of the subgingival microflora. METHOD: The study included 59 periodontitis patients (mean age 41.5 years): 30 smokers and 29 nonsmokers. The treatment consisted of initial periodontal therapy and, if necessary, surgery and/or antibiotics. Clinical and microbiological data were obtained before and after treatment at the deepest site in each quadrant. A pooled sample was analysed for the presence of Actinobacillus actinomycetemcomitans (Aa), Porphyromonas gingivalis (Pg), Prevotalla intermedia (Pi), Bacteroides forsythus (Bf), Fusobacterium nucleatum (Fn) and Peptostreptococcus micros (Pm). RESULTS: For smokers and nonsmokers a significant improvement of the clinical condition was found after treatment. A decrease could be assessed for bleeding on probing (smokers: 0.46; nonsmokers: 0.52) and probing pocket depth (PPD) (smokers: 1.64 mm; nonsmokers: 2.09 mm). Furthermore, both groups showed gain of attachment (smokers: 0.68 mm; nonsmokers: 1.46 mm). No significant difference in bleeding on probing and PPD reduction was found between smokers and nonsmokers. In contrast, nonsmokers showed significantly more gain of attachment than smokers. The microbiological results revealed no differences in the prevalence of the various bacteria between smokers and nonsmokers before treatment. After treatment in nonsmokers, a significant decrease was found in the prevalence of Aa (11-3), Pg (17-7), Pi (27-11), Bf (27-11), Fn (28-20) and Pm (27-17). In smokers, a significant decrease could be shown only for the prevalence of Pg (15-5). CONCLUSIONS: Nonsmokers showed more gain of attachment and a greater decrease in the prevalence of periodontal bacteria as compared to smokers. The phenomenon that among smokers, more patients remain culture positive for periodontal pathogens after therapy, may contribute to the often observed unfavourable treatment results in smoker periodontitis patients.     

Systemic metronidazole in the treatment of periodontitis

The present study evaluated the effect of systemic metronidazole on advanced periodontitis in 10 patients with inadequate oral hygiene. Clinical and microbiological observations were made at a total of 173 bleeding pockets of 5 mm depth or more. The clinical observations comprised plaque index scores, dichotomous measurements of gingival redness and suppuration, pocket depths and attachment levels. The microbiological variables investigated were the % spirochaetes, % black-pigmented Bacteroides species, % facultative streptococci and presence of absence of Bacteroides gingivalis. At baseline, after clinical measurements and microbiological samples had been taken, each patient received a thorough scaling and root planing. After 3 months, the clinical measurements and microbiological sampling were repeated and a 5-day course of metronidazole was administered while one side of the mouth was scaled and root planed. After a further 3 months, the final measurements and samples were taken. In comparing pre- and post-treatment data, the following significant differences were observed: for debridement alone, a reduction in mean % spirochaetes from 11.5% to 4.9% and an increase in mean % streptococci from 4.7% to 8.8%; for metronidazole alone, a 0.3 mm gain in mean attachment level, a 0.4 mm reduction in mean pocket depth and a reduction in the frequency of suppurating sites from 32% to 16%; for debridement plus metronidazole, a 0.2 mm gain in mean attachment level, a 0.5 mm reduction in mean pocket depth and a reduction in mean % spirochaetes from 5.6% to 2.5%. Thus systemic metronidazole, either alone or accompanied by debridement, produced a modest clinical improvement after debridement alone had failed.(ABSTRACT TRUNCATED AT 250 WORDS)     

Microbiological markers for prediction and assessment of treatment outcome following non-surgical periodontal therapy

BACKGROUND: Actinobacillus actinomycetemcomitans, Porphyromonas gingivalis, and Bacteroides forsythus are considered major putative periodontal pathogens. However, it remains unclear what combinations or what levels of these bacteria influence treatment outcome. The purpose of the present study was to establish useful pathogenic markers for prediction and assessment of treatment outcome following scaling and root planing (SRP). METHODS: A total of 1,149 sites in 104 chronic periodontitis patients were clinically examined at baseline. Three months after SRP, 606 sites in 56 of these patients were reexamined. Subgingival plaque samples taken from the examined sites at baseline and 3 months were analyzed for the detection and quantification of A. actinomycetemcomitans, P. gingivalis, and B. forsythus using a colorimetric polymerase chain reaction technique. RESULTS: At baseline, high levels and a combination of P. gingivalis and B. forsythus were frequently detected in diseased sites (74%). SRP reduced the levels and the coexistence of P. gingivalis and B. forsythus (from 75% to 43%). However, in treated sites where there was less reduction of probing depth (<2 mm), or where bleeding on probing (BOP) or suppuration was detected, residual coexistence of P. gingivalis and B. forsythus and a high level of P. gingivalis after SRP were significantly more frequent. Furthermore, SRP did not improve BOP at sites exhibiting initially high levels of A. actinomycetemcomitans. CONCLUSIONS: These results suggest that the combination of P. gingivalis and B. forsythus, as well as the level of P. gingivalis, is useful in assessing treatment outcome. Furthermore, the high level of A. actinomycetemcomitans before SRP is a possible valuable predictor of treatment outcome.     

Comparison of clinical outcomes following treatment of chronic adult periodontitis with subgingival scaling or subgingival scaling plus metronidazole gel

BACKGROUND, AIMS: Conventional treatment of chronic periodontitis involves mechanical debridement of periodontal pockets. Recently, subgingival antimicrobials have been used adjunctively following such debridement. This 2-centre study compared the clinical effects of subgingival scaling (SRP) with SRP plus subgingival application of 25% metronidazole gel, Elyzol (SRP+gel), in patients with chronic adult periodontitis. METHOD: Voluntary informed written consent was obtained from 45 subjects at the Eastman (mean age 46, range 34-63) and 43 subjects at RAF Halton (mean age 47, range 34-71) who participated in this blind, randomised split-mouth design study. All had at least 2 sites in each quadrant with probing pocket depth (PPD) > or = 5 mm. PPD, bleeding on probing (BOP), and clinical probing attachment levels (CAL) measured using a stent, were recorded at baseline and at 1, 3, 6 and 9 months post-therapy. After subgingival scaling of all quadrants, 2 quadrants were randomly selected to be treated with metronidazole gel. RESULTS: A paired t-test on baseline values showed no bias between groups. Both treatments effectively reduced the signs of periodontitis. At each follow-up visit, reduction in PPD, CAL and BOP after the combined treatment was greater than for SRP alone. Paired t-tests showed that the improvement in the SRP+gel group was statistically significantly better (p<0.001) than for SRP alone (mean 0.5 +/- 0.6 mm. 95% CI 0.4-0.6 mm.) Similarly, the % of sites which improved to a final pocket depth of < or = 3 mm and the % of sites which improved over the 9 months of the study by as much as > or = 2 mm were greater for SRP+gel than for SRP alone. CONCLUSIONS: At the end of the study, the mean reductions for PPD were 1.0 mm (SRP) compared to 1.5 mm (SRP+gel), and for CAL they were 0.4 mm (SRP) compared to 0.8 mm (SRP+gel), with mean difference for CAL between treatments of 0.4 +/- 0.6 mm (95% confidence intervals of 0.3-0.6 mm). The combination therapy of SRP+gel was superior to the conventional treatment of SRP alone, and these differences were maintained for 9 months.