Is antibiotic therapy justified in the treatment of human chronic inflammatory periodontal disease?

New insight into the possible involvement of specific bacteria in the etiology of periodontal disease has stimulated interest in antibiotic therapy. However, current knowledge does not allow the designation of one or more pathogens in periodontal diseases. Some bacteria are considered suspected periodontal pathogens due to their predominance in the pocket and their potential pathogenicity, yet they all appear to be indigenous bacteria. For this reason, one can question the rationale for the use of antibiotics in the treatment of periodontal disease since the theoretical basis for their application seems small. Several reports of clinical trials in which antibiotics were administered as an adjunct to scaling and rootplaning in adult periodontitis conclude with encouraging statements concerning bacterial inhibition and the cure of inflammatory periodontal disease. However, the data are conflicting and mostly negative. Antibiotic treatment in combination with scaling and rootplaning in juvenile periodontitis and refractory adult periodontitis has shown some benefit, but the clinical trials were not sufficiently controlled to permit conclusions. So far, antibiotics have been applied as a last resort in order to supplement the non-specific approach of mechanical root debridement, but it can be doubted whether this approach offers any benefit in the long run.     

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??The aim of periodontal therapy is to remove inflammation and prevent disease progression. Thorough debridement of subgingival root surfaces is considered as the gold standard of periodontal therapy. Conventional periodontal treatment technology includes blinded closed scaling/root planing??SRP??and open flap surgery. SRP is a standard treatment modality?? but whether the treatment is complete relies on tactile perception. However the traditional tactile perception of the subgingival root surface is without visual accessibility and lacks sensitivity and specificity. Many aspects of clinical practice limit the clinician′s ability. The precise evaluation of subgingival accretions, root surfaces??and soft tissues under the endoscope is critical for diagnosing periodontitis??planning treatment??and estimating the benefits of therapy. In this paper??the structure and characteristics of the endoscope and its clinical application in the periodontology are discussed.     

内窥镜在牙周诊疗中的应用进展

牙周病治疗的总体目标是消除炎症和防止疾病进展。彻底的龈下清创术是牙周治疗的金标准。传统的牙周治疗技术包括盲法闭合龈下刮治、根面平整（SRP）和开放式翻瓣刮治手术。前者是标准的治疗方式,治疗是否完善要靠触觉感知,但龈下的触觉感知没有视觉可达性,且缺乏敏感性、特异性,会导致结石残留。而且很多因素限制了临床医生检测和去除牙结石的能力。内窥镜提供了明确的龈下空间,可精确地评估龈下的根表面和软组织情况,对于牙周炎的诊断、治疗和疗效评估至关重要。文章就内窥镜的构造、特点及其在牙周领域的临床应用进行讨论。     

Microbiological shifts in intra- and extraoral habitats following mechanical periodontal therapy

OBJECTIVES: The aim of the present study was to analyze the intra- and extraoral colonization dynamics of periodontal pathogens following supra- and subgingival debridement. MATERIAL AND METHODS: Thirty five patients with chronic periodontitis were enrolled in the study. Supra- and subgingival plaque samples, saliva, and swab samples from mucosa and extraoral sites were taken at baseline and 6 weeks, 3 months and 6 months after mechanical periodontal therapy. Actinobacillus actinomycetemcomitans (Aa), Porphyromonas gingivalis (Pg), Eikenella corrodens (Ec), Tannerella forsythensis (Tf), Prevotella intermedia (Pi), Prevotella nigrescens (Pn), and Treponema denticola (Td) were identified by PCR. RESULTS: Supra- and subgingival debridement decreased the number of subgingival sites infected with the analyzed pathogens only transiently, if at all. However, the detection frequencies of Tf, Td, Ec, Pi, and Pn in the supragingival region, of Pg, Td, and Pn at the oral mucosa sites (mostly the tongue), and of all pathogens except Aa in saliva increased over the 6-month observation period. Td was the only pathogen recorded in notable quantities in the extraoral habitat (external ear canal). CONCLUSION: The results indicate that supra- and subgingival debridement results in a dissemination of periodontal pathogens within the oral cavity.     

The effect of systemic antibiotics in the treatment of patients with recurrent periodontitis

BACKGROUND: Subjects with periodontal disease exist who either (i) respond poorly to initial mechanical therapy ("refractory" periodontitis) or (ii) fail to adopt adequate self-performed plaque control techniques and hence develop recurrent disease ("recurrent" periodontitis) at multiple sites during the supportive treatment phase (SPT). Various systemic antibiotic regimens have been tried as adjuncts to the mechanical (re-) treatment of such "difficult to treat"-patients. While most studies indicated a positive outcome of the adjunctive therapy, some clinical investigators reported that this additional measure provided little or no benefit. AIM: The aim of the present investigation was to study the more long term effect of adjunctive antibiotic therapy in the re-treatment of patients with a well defined history of recurrent periodontitis. MATERIAL AND METHODS: 17 subjects with recurrent advanced periodontal disease were, following a baseline examination, subjected to non-surgical therapy including the use of systemic antibiotics (amoxicillin and metronidazole). They were placed in a careful SPT program and re-examined after 1, 3 and 5 years. The examinations included both clinical and microbiological assessments. RESULTS: It was demonstrated that in subjects with advanced and recurrent periodontitis, re-treatment including (i) comprehensive scaling and root planing (SRP), (ii) systemic administration of antibiotics and (iii) meticulous supragingival plaque control by both mechanical and chemical means established periodontal conditions that in the short term (3 years) and in the majority of subjects could be properly maintained by traditional SPT measures. Between 3 and 5 years, however, only 5 of the 17 subjects exhibited stable periodontal attachment levels. CONCLUSIONS: Some deep pockets and furcations were most likely inadequately instrumented during the active treatment phase. Microorganisms residing in biofilms left in such locations were probably not sufficiently affected by the 2 weeks of adjunctive antibiotic therapy. It is suggested that removal of certain subgingival deposits, therefore, may require surgical intervention.     

Dental bacterial plaques

Antony van Leeuwenhoek first described oral bacteria. However, not until almost 200 years later was the famous Koch postulate introduced. Since then, research has extensively been performed regarding the development and microbiology of dental plaques. In spite of the complexity of the developing flora of supragingival plaque, culture studies have shown a remarkably orderly succession of organisms. Lately, the concept of microbial specificity in the etiology of periodontal diseases has been widely suggested, i.e., that different forms of periodontal disease are associated with qualitatively distinct dental plaques. Cross-sectional and longitudinal studies of the predominant cultivable microflora reveal that only a small number of the over 300 species found in human subgingival plaques are associated with periodontal disease. Among the commonly mentioned are: Actinobacillus actinomycetemcomitans, Bacteroides gingivalis, Bacteroides intermedius, Capnocytophaga sp., Eikenella corrodens, Fusobacterium nucleatum, and Wolinella recta, as well as certain gram-positive bacteria such as Eubacterium species. Anti-infective therapy for many systemic infections equals the use of antimicrobial drugs. However, for localized infections like periodontal diseases, treatment may consist of a combination of mechanical wound debridement and the application of an antimicrobial agent. The general effectiveness of mechanical anti-infective therapy and successful oral hygiene in the management of periodontal disease is well established in the literature and has met the test of success in clinical practice for most cases of periodontitis in adults. The definition of periodontal pathogens as either opportunistic pathogens, or as exogenous pathogens carries with it significant implications.(ABSTRACT TRUNCATED AT 250 WORDS)     

Antibiotics in periodontal therapy: advantages and disadvantages*

Abstract. Antibiotic treatment of periodontitis aims at eradicating or controlling specific pathogens. Prime candidates for antibiotic therapy are patients with recently diagnosed active periodontitis or a history of recurrent disease who fail to stabilize following mechanical/surgical therapy. Since a variety of microbes with differing antimicrobial susceptibility profiles may cause periodontitis, selection of antimicrobial agents should be based on proper microbial diagnosis and sensitivity testing, as well as consideration of the patient's medical status. The risk of treating chemotherapeutically solely on the basis of clinical features, radiographic findings or a limited microbiological analysis, is failure to control the pathogens or overgrowth of new pathogens. A review of published papers reveals that appropriate systemic antibiotic therapy may enhance healing in patients with recent or high risk of periodontal breakdown. Systemic antibiotic therapy seems more predictable than topical administration in eradicating periodontal pathogens from deep periodontal pockets. Several promising antimicrobial agents for periodontitis treatment need testing in placebo-controlled, double-blind, randomized clinical trials.     

Microbiology in the management of destructive periodontal diseasea

This paper summarizes the rationale for the application of microbiology in the management of destructive periodontal diseases. The subgingival microbiota in patients with severe periodontitis is complex and contains high numbers of obligate anaerobic bacteria as well as facultative micro-organisms. It has become clear that major differences exist in the composition of the subgingival microflora. These differences are not only quantitative but also qualitative. Difference in plaque composition is the basis for the application of clinical microbiology in the management of periodontal disease. Several bacterial species have emerged as useful indicators for progressive periodontitis. In this respect, the importance of Actinobacillus actinomycetemcomitans, Bacteroides gingivalis and Bacteroides intermedius has been shown in a number of studies. It has become clear that A. actinomycetemcomitans is not specifically associated with the local form of juvenile periodontitis, but this micro-organism is probably also of importance in severe periodontitis in adult patients. Selection of individuals with an A. actinomycetemcomitans associated periodontitis is essential since successful treatment in these patients needs an adjunctive antibiotic therapy. Microbiological testing can be useful in patients showing a poor response to periodontal treatment (refractory periodontitis). Factors which may be responsible include poor oral hygiene, poor subgingival debridement, the patient's susceptibility and a subgingival microflora resistant to therapy. In this patient category, microbiological testing is capable of diverting continuing periodontal treatment. Furthermore, microbiology can be useful in evaluating periodontal treatment. Successful elimination of specific periodontopathic microorganisms can be used to determine recall intervals.     

Non-surgical periodontal therapy: An update on current evidence

Periodontal disease is an inflammatory condition that involves a complex interaction between pathogenic bacteria, environmental and acquired factors and host related factors. Till recently periodontal treatment was directed primarily towards reduction of bacterial load by subgingival debridement of root surfaces and modification of environmental risk factors. The current paradigm of periodontal disease stresses greater role of host-mediated inflammatory response in tissue destruction characteristic of periodontal disease. Various therapeutic modalities have been developed adjuvant to mechanical periodontal therapy. The use of laser and photodynamic therapy show great promise but their effectiveness has still not been conclusively proven. Chemotherapeutic agents, either systemic and local antimicrobials or host modulating drugs, played pivotal role in better and more predictable management of periodontal disease. The present review focuses on the best available evidence, for the current management of the chronic periodontal patients, gathered from systematic reviews and meta-analysis of mechanical non surgical periodontal therapy (NSPT) (subgingival debridement, laser therapy and photodynamic therapy) and the adjunctive chemotherapeutic approaches such as systematic and local antibiotics and antiseptics, subgingival pocket irrigation and host modulation therapies. The review also attempts to briefly introduce future developments in some of these modalities. At the end, the review summarizes the analysis of the current evidence that suggests that thorough subgingival debridement remains the mainstay of NSPT and that adjunct use of chemotherapeutic agents may offer better management of clinical parameters in periodontitis patients.     

以菌斑控制为导向的牙周治疗联合引导性组织再生术病例分析1例

牙周炎是一种以菌斑为主要致病因素的慢性感染性疾病,控制菌斑和消除炎症是牙周炎治疗的首要目标,在菌斑控制的基础上,再实现恢复牙周组织的功能、恢复牙周组织生理形态、维持长期疗效防止复发等目标,从而使牙周组织保持健康状态。本文报道了一例牙周炎第III阶段、B级的患者,基础治疗时采用以菌斑控制为导向的牙周治疗,炎症控制后对具有深牙周袋位点进行GTR联合植骨术,患者定期复查,获得满意疗效。     

Metronidazole plus amoxycillin in the treatment of Actinobacillus associated periodontitis

The potential use of an adjunctive therapy of metronidazole plus amoxycillin for the subgingival elimination of Actinobacillus actinomycetemcomitans in periodontitis patients was investigated. 22 patients participated in this study, 11 with localized juvenile periodontitis (LJP) and 11 with rapidly progressive periodontitis (RPP). 14 patients had received periodontal treatment in the past. All patients were subgingivally infected with A. actinomycetemcomitans. After mechanical subgingival debridement in combination with the antibiotic treatment, elimination of A. actinomycetemcomitans was achieved in all patients but one. With this one exception, clinical improvements were observed in all patients, resulting in reduced pocket probing depths as well as in a significant reduction in bleeding on probing. Re-examination of 16 patients after 9-11 months revealed that A. actinomycetemcomitans was still undetectable and further clinical improvement was observed. It was concluded that the combination of metronidazole plus amoxycillin is a valuable adjunct to mechanical therapy in A. actinomycetemcomitans associated periodontal infections.     

Systemic antibiotics in periodontal therapy

Periodontitis is a biofilm infection with a mixed microbial aetiology. Periodontitis is generally treated by non-surgical mechanical debridement and regular periodontal maintenance care. Periodontal surgery may be indicated for some patients to improve access to the root surface for mechanical debridement. A range of systemic antibiotics for treatment of periodontitis has been documented, with some studies showing superior clinical outcomes following adjunctive antibiotics while others do not. This has resulted in controversy as to the role of systemic antibiotics in the treatment of periodontal diseases. Recent systematic reviews have provided an evidence-based assessment of the possible benefits of adjunctive antibiotics in periodontal therapy. This review aims to provide an update on clinical issues of when and how to prescribe systemic antibiotics in periodontal therapy.     

Patient self‐care of periodontal pocket infections

Treatment of periodontitis aims to control the infection caused by the periodontal pathogenic flora and includes mechanical debridement of root surfaces to disrupt the supragingival and subgingival biofilm. As periodontal pockets of ≤ 5 mm can be perform in a stable condition and may not need additional therapy, the ability and the willingness of the patient to perform good oral hygiene on a long‐term basis are of utmost importance for ensuring long‐term success of periodontal treatment. In this context, the aim of all home‐care measures must be the optimal control of plaque biofilm in order to prevent or treat gingival inflammation as a primary stage of periodontitis. Despite the fact that toothbrushing and other mechanical cleaning practices are the most important elements for preventing periodontal diseases or their progression, other factors, including education, motivation, manual dexterity and compliance with professional recommendation, provision of time and socio‐economic status, as well as risk factors, play a role. The present article provides an overview on the various possibilities for self‐care of residual pockets in patients with periodontitis.     

Antimicrobials for the treatment of aggressive periodontitis

Aggressive periodontitis is characterized by a considerable attachment loss over a relatively short period of time. It may be the consequence of either the presence of highly aggressive pathogens or a highly susceptible host. In the first case, the use of antimicrobials should be beneficial in the treatment of those patients. However, due to the organization of the micro-organisms as a biofilm, the increasing incidence of allergies and resistance against antimicrobials and their side-effects, there is still controversy about their benefit in the treatment of periodontal disease. This paper discusses indications for the use of antimicrobials, the substances prescribed and the type of application under the conditions of aggressive periodontitis.     

Focal infection of periodontal origin

Periodontology has evolved from a predominantly mechanical to a sophisticated infectious disease‐based discipline. Research has paved the way for a greater understanding of the periodontal microbiome, improvement in periodontal diagnostics and therapies, and the recognition of periodontitis being associated with more than 50 systemic diseases. The etiopathology of progressive periodontitis includes active herpesviruses, specific bacterial pathogens, and proinflammatory immune responses. This article points to a role of periodontal herpesviruses in the development of systemic diseases and proposes treatment of severe periodontitis not only to avoid tooth loss, but also to reduce the risk for systemic diseases. An efficient, safe, and reliable anti‐infective treatment of severe periodontitis is presented, which targets both herpesviruses and bacterial pathogens and which can be carried out in minimal time with minimal cost.     

Aggressive periodontitis associated with Papillon-Lefèvre syndrome: Report of a 14-year follow-up

This case report describes the periodontal management, therapeutic approach, and 14-year follow-up of a patient diagnosed with Papillon-Lefèvre syndrome (PLS).
A female child, diagnosed with PLS-associated periodontitis at the age of 9 years and 11 months, presented with hyperkeratosis of the palms and soles, as well as generalized aggressive periodontitis. The dental treatment comprised standard periodontal debridement, scaling and root planing, instructions on oral hygiene, restorations, extraction of hopelessly affected teeth and a therapeutic use of antibiotics.
The concomitant supportive periodontal therapy and antibiotic coverage could not stop the loss of periodontal attachment and destruction of the alveolar bone. Four years after treatment was initiated, the last remaining teeth were extracted and complete dentures were constructed. The dentures have been periodically replaced and the patient continues to return for follow-up once a year.
The combination of intensive periodontal treatment and antibiotic regimen only temporarily delayed periodontal disease progression and did not prevent loss of both primary and permanent teeth. The outcome of this long-term follow-up case report shows that management of PLS-associated periodontitis is further complicated when the patient is first seen in the mixed dentition stage or later. In these situations, the chances of controlling the progression of periodontal breakdown and minimizing tooth loss are greatly reduced.     

Influence of residual pockets on progression of periodontitis and tooth loss: results after 11 years of maintenance

Background: Limited evidence exists on the significance of residual probing pocket depth (PPD) as a predictive parameter for periodontal disease progression and tooth loss.
Aim: The aim of this study was to investigate the influence of residual PPD 5 mm and bleeding on probing (BOP) after active periodontal therapy (APT) on the progression of periodontitis and tooth loss.
Material and Methods: In this retrospective cohort, 172 patients were examined after APT and supportive periodontal therapy (SPT) for 3–27 years (mean 11.3 years). Analyses were conducted using information at site, tooth and patient levels. The association of risk factors with tooth loss and progression of periodontitis was investigated using multilevel logistic regression analysis.
Results: The number of residual PPD increased during SPT. Compared with PPD3 mm, PPD=5 mm represented a risk factor for tooth loss with odds ratios of 5.8 and 7.7, respectively, at site and tooth levels. The corresponding odds ratios for PPD=6 mm were 9.3 and 11.0 and for PPD7 mm 37.9 and 64.2, respectively. At patient level, heavy smoking, initial diagnosis, duration of SPT and PPD6 mm were risk factors for disease progression, while PPD6 mm and BOP30% represented a risk for tooth loss.
Conclusion: Residual PPD6 mm represent an incomplete periodontal treatment outcome and require further therapy.     

Treatment of aggressive periodontitis

Despite etiological differences between aggressive and chronic periodontitis, the treatment concept for aggressive periodontitis is largely similar to that for chronic periodontitis. The goal of treatment is to create a clinical condition that is conducive to retaining as many teeth as possible for as long as possible. When a diagnosis has been made and risk factors have been identified, active treatment is commenced. The initial phase of active treatment consists of mechanical debridement, either alone or supplemented with antimicrobial drugs. Scaling and root planing has been shown to be effective in improving clinical indices, but does not always guarantee long‐term stability. Antimicrobials can play a significant role in controlling aggressive periodontitis. Few studies have been published on this subject for localized aggressive periodontitis, but generalized aggressive periodontitis has been subject to more scrutiny. Studies have demonstrated that systemic antibiotics as an adjuvant to scaling and root planing are more effective in controlling disease compared with scaling and root planing alone or with supplemental application of local antibiotics or antiseptics. It has also become apparent that antibiotics ought to be administered with, or just after, mechanical debridement. Several studies have shown that regimens of amoxicillin combined with metronidazole or regimens of clindamycin are the most effective and are preferable to regimens containing doxycycline. Azithromycin has been shown to be a valid alternative to the regimen of amoxicillin plus metronidazole. A limited number of studies have been published on surgical treatment in patients with aggressive periodontitis, but the studies available show that the effect can be comparable with the effect on patients with chronic periodontitis, provided that proper oral hygiene is maintained, a strict maintenance program is followed and modifiable risk factors are controlled. Both access surgery and regenerative techniques have shown good results in patients with aggressive periodontitis. Once good periodontal health has been obtained, patients must be enrolled in a strict maintenance program that is directed toward controlling risk factors for disease recurrence and tooth loss. The most significant risk factors are noncompliance with regular maintenance care, smoking, high gingival bleeding index and poor plaque control. There is no evidence to suggest that daily use of antiseptic agents should be part of the supportive periodontal therapy for aggressive periodontitis.     

New views on periodontal microbiota in special patient categories

The microorganisms in periodontitis of special patient categories have been only partially elucidated. The periodontitis microbiota of HIV-infected individuals, cancer patients on myelosuppressive therapy, and persons with other medical disorders includes common suspected periodontal pathogens as well as enteric rods, pseudomonads, staphylococci and yeasts. Failing implants also may be associated with classical periodontal pathogens as well as primarily nonoral potential pathogens. Refractory periodontitis in systemically healthy adults can show a great variety of oral and nonoral organisms. The frequent occurrence of unusual periodontal organisms in special patient categories may be due to a weakened host response and/or usage of various chemotherapeutic regimens. The unusual organisms may contribute to progressive periodontitis and in leukemia patients may even give rise to life-threatening systemic manifestations. The primary therapeutic goal in special periodontitis patients is control of pathogens and amid the wide range of pathogenic microfloras, an effective treatment strategy should include a comprehensive microbiological analysis, especially if systemic antimicrobial therapy is contemplated.     

Primer on etiology and treatment of progressive/severe periodontitis: A systemic health perspective

Periodontology is an infectious disease-based discipline. The etiopathology of progressive/severe periodontitis includes active herpesviruses, specific bacterial pathogens, and proinflammatory cytokines. Herpesviruses and periodontopathic bacteria may interact synergistically to produce periodontal breakdown, and periodontal herpesviruses may contribute to systemic diseases. The infectious agents of severe periodontitis reside in deep pockets, furcation lesions, and inflamed gingiva, sites inaccessible by conventional (purely mechanical) surgical or nonsurgical therapy but accessible by systemic antibiotic treatment. This brief overview presents an effective anti-infective treatment of severe periodontitis, which includes systemic chemotherapy/antibiotics against herpesviruses (valacyclovir [acyclovir]) and bacterial pathogens (amoxicillin + metronidazole or ciprofloxacin + metronidazole) plus common antiseptics (povidone-iodine and sodium hypochlorite) and select ultrasonic scaling. The proposed treatment can cause a marked reduction or elimination of major periodontal pathogens, is acceptably safe, and can be carried out in minimal time with minimal cost.