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.     

Selection of antimicrobial agents in periodontal therapy

BACKGROUND: The recognition over the past 3 decades of microbial specificity in periodontitis has afforded dental practitioners the ability to prevent and treat the disease with a variety of antimicrobial drugs. These include systemic antibiotics, topical antibiotics and topical antiseptics. RESULTS: Systemic antibiotic therapy can be essential in eliminating pathogenic bacteria that invade gingival tissue and in helping control periodontal pathogens residing in various domains of the mouth from where they may translocate to periodontal sites. Frequently used periodontal combination antibiotic therapies are metronidazole-amoxicillin (250-375 mg of each 3 x daily for 8 days) and metronidazole-ciprofloxacin (500 mg of each 2 x daily for 8 days). Microbiological analysis helps determine the optimal antibiotic therapy and effectiveness of treatment. Topical antibiotics that are commercially available as controlled release devices suffer from several potential problems, including insufficient spectrum of antimicrobial activity in some periodontal polymicrobial infections, risks of producing an antibiotic resistant microbiota, and high acquisition costs. Topical antiseptics of relevance in periodontal treatment include 10% povidone-iodine placed subgingivally by a syringe for 5 min, and 0.1% sodium hypochlorite solution applied subgingivally by patients using an irrigation device. CLINICAL IMPLICATIONS: The present paper recommends periodontal treatment that includes a battery of professionally and patient-administered antimicrobial agents (properly prescribed systemic antibiotics, povidone-iodine and sodium hypochlorite subgingival irrigants, and chlorhexidine mouthrinse). Available chemotherapeutics can provide effective, safe, practical and affordable means of controlling subgingival colonization of periodontal pathogens and various types of periodontal disease.     

Systemic antimicrobials in the treatment of chronic periodontal diseases: a dilemma

The use of systemic antimicrobials in the treatment of acute and chronic periodontal diseases must be viewed as a dilemma. On the one hand, the approach is attractive because of the microbial nature of periodontal diseases but, on the other hand, evidence of benefit of these agents is equivocal for the majority of periodontal diseases and antimicrobials have the potential to cause harm. The disadvantages of systemic antimicrobials can be grouped under the headings of allergic reactions, superinfection, toxicity, drug interactions, patient compliance and, perhaps of most widespread importance, bacterial resistance. Mechanical debridement methods, including drainage of pus for acute periodontal abscesses, should be considered the first line treatment for most periodontal diseases. Systemic antimicrobials should be considered as adjuncts to mechanical debridement methods and, in chronic disease, never used alone as they can predispose to abscess formation. Adjunctive systemic antimicrobials may be considered in acute disease where debridement or drainage of pus is difficult, where there is local spread or systemic upset. In chronic periodontal diseases, adjunctive antimicrobials should be considered in early onset or rapidly progressive disease or in advanced chronic adult disease where mechanical therapies have failed or surgery is not a preferred option. Inadequate oral hygiene and tobacco smoking are contra-indications to the use of antimicrobials. The value of systemic antimicrobials, where other systemic risk factors co-exist, has still to be established. The role of microbial diagnosis and sensitivity testing for antimicrobial selection at this time must be questioned.     

Factors associated with pain and analgesic consumption following non‐surgical periodontal therapy under local anaesthesia and carried out by dental students

Aim

Evaluate factors associated with pain and analgesic consumption following non‐surgical periodontal therapy.

Materials and methods

The sample consisted of 218 patients with chronic periodontitis, submitted to non‐surgical scaling and root planing under local anaesthesia at a public dental service in southern Brazil. The data collection instruments included a demographic questionnaire, as well as State‐Trait Anxiety Inventory, Corah?s Dental Anxiety Scale, Visual Analogue Scale, Numerical Rating Scale and Verbal Rating Scale. The presence and intensity of pain were evaluated at 2, 6, 12, 24 and 48 hr after scaling and root planing.

Results

A total of 52.3% of the patients reported mild intensity pain at some point during the 48 hr after scaling and root planing with local anaesthesia. Smoking (PR = 1.47; 95% CI = 1.16–1.65), severe periodontal inflammation (PR = 1.31; 95% CI = 1.09–1.58) and dental anxiety (PR = 1.24; 95% CI = 1.03–1.49) were associated with postoperative pain after adjusting for age, gender and state and trait anxiety scores. Moreover, 46.8% of the subjects used analgesics at some time during the 48‐hr follow‐up period and dental anxiety was the only factor associated with postoperative analgesic use.

Conclusions

Smoking, severe periodontal inflammation and dental anxiety were identified as factors associated with pain after non‐surgical scaling and root planing with local anaesthesia. Dental anxiety was also a factor associated with postoperative analgesic use.     

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.     

Primer for antimicrobial periodontal therapy

Successful prevention and treatment of periodontitis is contingent upon effective control of the periodontopathic microbiota. Periodontal pathogens reside in subgingival sites but also colonize supragingival plaque, tongue dorsum and other oral sites. Controlling destructive periodontal disease warrants a comprehensive antimicrobial approach that targets periodontal pathogens in various ecological niches of the oral cavity. Also, to effectively combat periodontal pathogens, the various elements of antimicrobial periodontal therapy should be engaged within a short period of time. Scaling and root planing, with or without periodontal surgery, along with proper oral hygiene, constitute the primary approach to controlling periodontopathogens. Antimicrobial agents administered systemically or locally can help suppress periodontal pathogens in periodontal sites and in the entire mouth. Microbiological testing aids the clinician in selecting the most effective antimicrobial agent or combination of agents, and in monitoring the effectiveness of periodontal treatment. The present paper considers theoretical and practical aspects of effective antimicrobial treatment of destructive periodontal disease.     

Pulpal disease and bursts of periodontal attachment loss

Progression of periodontitis is currently thought to occur during bursts of activity, followed by periods of remission, when healing may occur. This concept contrasts with the older hypothesis that periodontitis was continuously, but slowly, progressive throughout life. At present, there is no proof of the conventional (microbiological) hypothesis which gives a major role to site-specific bacteria in the initiation of bursts of attachment loss. An alternative hypothesis is presented in this paper which accounts for periodontal attachment loss by pathways that are independent of plaque. Severe lesions of the periodontium caused by pulpal pathoses (apical and retrograde periodontitis) are known to form at any level of the periodontium, not only at the root apex. When these lesions cause destruction of the periodontal tissues at the alveolar crest, and when plaque, calculus and gingivitis are also present, an endodontic origin is rarely suspected. Three pathways are proposed to account for the development of localized periodontal attachment loss consequent to pulpal disease. This hypothesis accounts for the sudden deterioration of periodontal sites under regular review, the strict localization of alveolar defects with normal alveolar bone immediately adjacent, the presence of site-specific bacteria (secondary colonizers of deep pockets) which cannot cause disease when transferred to healthy sites, and the antibody responses directed against them.     

我军现役人员口腔健康现状的变化和发展

目的:调查15年期间我军男性现役人员龋病、牙周病的流行状况和变化趋势。方法:1993、2008年利用抽样调查方法、2003年利用捷径调查方法对全军具有代表性的陆军、海军、空军等军种男性现役人员的龋病、牙周疾病状况进行口腔健康检查。结果:15年期间我军的龋病、牙周疾病的患病率和强度显著下降,海军龋齿患病率和活动性龋病高于陆军和空军。结论:15年期间我军男性现役人员口腔健康状况稳步提高,还需进一步改善海军的口腔卫生勤务保障能力。     

米诺环素辅助治疗急性牙周脓肿的临床效果

目的:评估米诺环素在辅助治疗急性牙周脓肿时的临床效果。方法:选择急性牙周脓肿病人65例,随机分为试验组和对照组。试验组33例,采用生理盐水5～10 mL牙周袋内冲洗和20 g/L盐酸米诺环素软膏袋内注射;对照组32例,采用生理盐水5～10 mL牙周袋内冲洗和局部上碘甘油并口服3 d抗生素。分别于基线和处理后第3天检查记录疼痛程度、脓肿大小、松动度、探诊出血、脓性渗出分数。结果:试验组和对照组疼痛程度、脓肿大小、牙松动度、探诊出血、脓性渗出分数各项指标均较治疗前明显改善(P=0.000),两组受试者治疗前后各项指标减轻程度差异无统计学意义(P>0.05)。试验组有效率87.9%,对照组有效率83.9%,二者差异无统计学意义(P>0.05)。试验组有2例在进行盐酸米诺环素牙周袋内注射时诉感疼痛;对照组有5例在服用抗生素后诉有胃肠道不适。结论:米诺环素局部使用辅助治疗急性牙周脓肿可达到传统治疗方法的疗效水平,从而减少口服抗生素的使用。     

Local antimicrobial therapy after initial periodontal treatment

AIM: The aim of this single-blind, randomized, parallel-designed clinical trial (RCT) was to evaluate the clinical and microbiological effects of three sustained-release biodegradable polymers delivered into periodontal pockets following initial periodontal therapy. METHODS: Forty-seven patients (28 females and 19 males) with a mean age of 51 years (range 29-71) underwent a periodontal examination at baseline (i.e. Week 0) and after 18 weeks. This included the assessment of the Plaque Index (PlI), Bleeding on Probing (BOP), Pocket Probing Depths (PPD) and Probing Attachment Levels (PAL) at six sites per tooth. Two to 4 months prior to baseline, all subjects had received initial periodontal therapy including motivation, instruction in oral hygiene practices and full-mouth scaling and root planing. At the treatment appointment (i.e. Week 2), the patients were randomly assigned to receive either Atridox trade mark, Elyzol Dental Gel or PerioChip at all residual periodontal pockets with a probing depth >/= 5 mm and concomitant BOP. In accordance with the manufacturer's recommendations, Elyzol Dental Gel was applied for a second time 7 days later. In addition to the clinical evaluation, subgingival microbiological samples were collected prior to treatment (i.e. Week 2) and at Weeks 4 and 18. Analysis of variance/covariance was used to evaluate changes from baseline to Week 18 for the clinical parameters. RESULTS: Between the baseline and 18-week examinations, subjects treated with Atridox showed a significantly greater gain in mean PAL of 0.33 mm +/- 0.09 (SD) than subjects treated with Elyzol Dental Gel [0.03 mm +/- 0.09 (SD)](p = 0.03). However, the gain in PAL of 0.16 mm +/- 0.10 (SD) found after PerioChip application did not differ significantly from that obtained following the application of Atridox(p = 0.27). Of the sites treated with Atridox, 42% gained >/= 1 mm PAL and 9% >/= 2 mm PAL as opposed to the sites treated with Elyzol Dental Gel, in which 34% gained >/= 1 mm PAL and 8% gained >/= 2 mm PAL. Of the sites treated with PerioChip, 36% gained >/= 1 mm and 6% gained >/= 2 mm PAL following a completed initial periodontal therapy. CONCLUSIONS: The application of the three biodegradable sustained release devices tested following initial periodontal therapy resulted in a statistically significant gain in mean PAL for AtridoxTM and a significant reduction in PPD for all three devices during the study period. Furthermore, when sites treated with Atridox were compared with sites treated with Elyzol, a significant difference in mean PAL gain (0.3 mm) was observed.     

基于催眠和认知行为疗法的儿童牙科行为管理

 恐惧是儿童牙科行为管理问题的核心，使患儿免于恐惧是行为管理的关键。借鉴催眠和认知行为疗法的理论与方法，由行为引导师带领患儿逐步逐级放松，培育积极正面牙科观念，最终实现自主配合牙科治疗的过程称为“行为管理”。针对常见的行为管理问题，文章简要介绍了快速赢得患儿信任、系统脱敏和记忆重构的引导流程。     

Dental patients''knowledge and beliefs about periodontal disease

The knowledge and beliefs about periodontal disease of 1093 regularly attending patients in 36 North Carolina general dental practices were examined. Patients had a strong positive orientation toward keeping their teeth. Correct information concerning the signs, causes, prevention, and treatment of periodontal disease was widely held. Older patients were more knowledgeable about treatment and signs of periodontal disease, while younger patients expressed more positive beliefs about keeping their teeth for a lifetime. Although patients' knowledge was not perfect, it included few misperceptions that could threaten oral health. Additional education was most needed with respect to the significance of bleeding gums.     

Caries, oral hygiene and periodontal disease in handicapped adults

Caries, periodontal disease, oral hygiene and treatment needs were assessed in a group of handicapped adults. The study group comprised 199 individuals aged 17-64 yr, most of whom were mentally subnormal. The mean DMFT values ranged from 17.4 in the 17-24-yr-old age group to 26.9 in the 55-64-yr-old age group. Tooth loss increased rapidly with advancing age. In all age groups the F component was less than 20% and high numbers of untreated carious lesions were found. Of the group studied, 90% needed some conservative treatment. Oral hygiene was poor and a high prevalence of periodontal disease was found. Of the dentulous persons, 49% needed scaling and 34% complex periodontal treatment. The percentage of study group patients requiring dental treatment was very high, so that it can be concluded that dental care for the handicapped is insufficient. This situation must be improved and a suitable system for the delivery of preventive measures must be devised for this group of the population.     

Impact of anxiety on pain perception associated with periodontal and implant surgery in a private practice

Background: There are limited data on pain perception after periodontal or implant surgery or how pain perception is affected by presurgical anxiety. Methods: Presurgical anxiety and surgical pain perceptions were measured by visual analog scale (VAS) scores and by interview of patients (N = 102) undergoing periodontal or implant therapy in a private periodontal specialty practice in Norway. Results: Patients reported that bad taste, receiving the local anesthetic, and excessive fluid in the mouth were the most uncomfortable experiences associated with periodontal or implant surgery. Analysis of identical responses to these questions showed that there was low intrapatient agreement for uncomfortable experiences (κ = 0.18), but there was reasonably good agreement for comfortable experiences (κ = 0.76). There were no significant differences between repeated VAS scores for pain perception (P = 0.91) or anxiety (P = 0.75) from two consecutive surgeries. There were no significant differences of VAS scores for perception of discomfort for periodontal surgery (9.9 ± 17.0) compared to implant surgery (16.7 ± 24.2; P >0.2). Presurgical anxiety scores were higher for implant surgery (45.5 ± 33.4) than for periodontal surgery (19.5 ± 28.1; P <0.01). Patients with high pretreatment anxiety scores reported that periodontal and implant surgery were more uncomfortable than patients with low anxiety scores (20.5 ± 25.6 versus 0.45 ± 1; P <0.001). VAS perception and anxiety scores did not change on first‐time through fourth‐time surgeries, but retreatment surgery patients recorded higher perception and anxiety VAS scores than patients undergoing surgery for the third or fourth time (P <0.01). Females recorded significantly higher anxiety scores than males (P = 0.04). Conclusion: For periodontal surgery and implant treatments pain perception is affected by the level of presurgical anxiety.     

Re-treatment profiles during long-term maintenance therapy in a periodontal practice in Norway

BACKGROUND: Periodontal therapy coupled with active maintenance has been shown to be effective in maintaining periodontal health, however, the question of re-treatment is rarely alluded to in the literature. AIM: To quantify the type and extent of re-treatment in a group of patients who had completed a definitive course of periodontal treatment in a Norwegian specialist periodontal practice. The study also investigated factors associated with the provision of periodontal surgery as a re-treatment modality. METHODS: A consecutive group of patients who had comprehensive periodontal treatment, which included periodontal surgery, and were subsequently maintained for between 10 and 17 years were studied. RESULTS: One hundred and one patients with an average age at reassessment of 59.4 (standard deviation (SD) 9.0) years were studied. The average length of the review period was 13.1 (SD 1.9) years. In addition to routine maintenance, 50 patients had further re-treatment and 40 of those who were re-treated had periodontal surgery in the study period. Logistic regression showed that independent predictors of surgical re-treatment, with the effects adjusted for other variables in the model, were uncertain or poor prognosis at baseline, erratic or poor post baseline compliance and a family history of periodontal disease. CONCLUSION: Considerable amounts of re-treatment, including in many cases extensive non-surgical treatment or periodontal surgery, were provided for patients who had surgical periodontal treatment and were subsequently maintained for least 10 years in a specialist periodontal practice.