Antibiotics and inflammation
New research published in the November 2015 issue of the Journal of Periodontology demonstrated the advantages of azithromycin (AZM) over amoxicillin (AMX) before dental implant placement. Its authors found that a single prophylactic dose of AZM appeared to alter inflammation and early healing after implant surgery. In addition, AZM remained at the surgical site for longer than AMX did.
The results are important because early failure of dental implants is often associated with complications in wound healing or excessive inflammation.
An antibiotic regimen of 2g AMX or 500 mg. of AMZ, for patients who are allergic to penicillin, is commonly administered to patients one hour before implant placement. Scientists sought to compare the antimicrobial and anti-inflammatory effects from a single dose of AMX or AZM before a one-stage implant surgical protocol. “The purpose of this study is to assess the resolution of postoperative peri-implant inflammation during early healing in the presence of two different systemic antibiotic regimens and compare it to the resolution of inflammation at the adjacent periodontal sites,” the authors reported. They designed their research based on the knowledge that AZM concentrations in fluid collected at the gingival margin or crevice, gingival crevicular fluid (GCF), are sustained for up to two weeks. Also, as a macrolide, AZM may produce a modulating effect on relevant immune functions.
To investigate, eight males and eight females who opted for one-stage placement of a dental implant between July 2012 and April 2013 at the Ohio State University Graduate Periodontology Clinic were enrolled. Each had two natural teeth adjacent to the site where the implant was to be placed.
Researchers divided the subjects into two groups: AMX and AZM. One hour before surgery, they assessed gingival index, plaque index and GCF volume for the teeth adjacent to the implant site. After placing the implant and healing abutment in a single procedure, scientists asked patients to use an antimicrobial rinse twice daily and avoid taking non-steroidal anti-inflammatories. Patients were provided with acetaminophen at 500 mg and instructed to take one tablet every six hours as needed for pain.
At six, 13 and 20 days after surgery they assessed plaque index at four surfaces of each implant site and at adjacent natural tooth sites. Scientists also collected GCF or peri-implant crevicular fluid (PICF) samples from the same four surfaces of the implant sites for a total of eight samples from the implant and eight from adjacent natural tooth sites at each of these follow-up visits. They took a sample of peripheral blood on day six.
Among the central discoveries were that the blood samples from the AZM group contained measurable amounts of antibiotic on days six and 13. “The finding confirms that AZM has a greater potential to influence postoperative healing around a new implant because it is eliminated less rapidly than AMX,” authors said. (Authors noted previous studies have shown that oral AMX produces peak blood levels one to two hours after administration and exhibits a short half-life.)
Changes from the baseline rate of GCF flow after implant placement were significantly lower in the AZM group, whereas the AMX group exhibited a significant increase in GCF flow rate on day six. It has been established that there is a strong correlation between histologic signs of inflammation and GCF volume. The result suggests that post-surgical inflammatory response was more constrained in the AZM group, according to authors.
Also among results, the AZM group demonstrated consistently lower volumes of PICF than the AMX group on days six and 14. Although the difference was not significant, it suggested to authors that post-surgical healing progressed more rapidly in the AZM group.
Within their conclusions, authors said the most remarkable finding of their research is that a single dose of AZM appeared to alter several potentially important aspects of inflammation and early healing after implant surgery. “The present results suggest that AZM has a favorable influence on healing, but additional studies are indicated to fully characterize the extent to which AZM alters the complex processes associated with the inflammatory response.”
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Consulting Editor: Tapan Koticha, BDS
Diplomate, American Board of Periodontology
Assistant Professor, Department of Periodontics,
Clinical Director, Graduate Periodontics
University of Oklahoma Health Sciences Center, College of Dentistry
Laser use in periodontology: a systematic review
Although the adjunctive use of lasers in non-surgical therapies has been demonstrated to improve outcomes, lack of consensus dominates professional discussion on the topic. Additionally, the effectiveness of lasers for surgical periodontal therapies is much debated and remains unclear.
Seeking to evaluate and compare laser treatments on their own or as an adjunct to surgical therapy, investigators from the University of Michigan conducted a systematic review and analysis and published their findings in the December 2015 issue of the Journal of Periodontology. To study, they focused their research on a single question: What is the effectiveness of laser adjunctive therapy in periodontal surgical treatment as measured by clinical parameters?
Two independent reviewers conducted an electronic search of articles in four databases up to December 2014 that reported on outcomes of surgical periodontal therapy with and without the use of lasers. They also performed a manual search of periodontics-related journals from January 2014 to December 2014.
According to their study design, the primary outcome for measurement and evaluation was probing depth. Secondary outcomes also measured were changes in clinical factors, including clinical attachment level (CAL) and gingival recession. Scientists compared clinical parameters among groups and calculated differences.
From an initial yield of 5,446 articles, nine fulfilled the inclusion criteria; one of those lacked analytical data. Eight articles were ultimately included in the analysis.
Results for the primary outcome measure showed that in flap surgery with or without laser treatment, there was no statistically significant difference in probing depth. The difference of probing depth in guided tissue regeneration (GTR)/enamel matrix derivative with and without laser treatment was also negligible. However, the GTR group without laser treatment showed better outcomes (probing depth reduction) than the laser group.
In discussion, authors noted applicability of lasers in the treatment of periodontal disease according to their theoretic advantages compared to conventional therapy is a very controversial topic in the field of periodontics. Advantages cited in the literature for non-surgical therapy are ablation, vaporization, hemostasis and sterilization.
“Findings from this study show that for regeneration and PD reduction surgical procedures, adjunctive use of lasers offers no significant clinical advantages in CAL gain and PD reduction compared with conventional approaches.”
Authors advised cautious interpretation of the study results, due to sample size limitations and heterogeneity among studies. More randomized clinical trials examining different laser types and wavelengths are required to obtain stronger conclusions, they said.
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Save the date
AAP Annual Meeting takes place in San Diego in September
The 102nd Annual Meeting of the American Academy of Periodontology will be held Sept. 10-13, 2016, at the San Diego Convention Center. This meeting will be held in collaboration with the Japanese Society of Periodontology and the Japanese Academy of Clinical Periodontology. Registration opens this spring.
For more information, visit perio.org/meetings or e-mail firstname.lastname@example.org.
MRONJ development and risk
The September 12, 2015, online edition of the Journal of Clinical Periodontology published a systematic review on the rate of medication related osteonecrosis of the jaw (MRONJ) after dental extractions in patients treated with antiresorptive drugs (ARD) for osteoporosis or oncological reasons. Extraction techniques in relation to occurrence of MRONJ were also evaluated.
Authors said antiresorptive drugs undeniably improve quality of life for cancer patients and reduce fractures in patients with osteoporosis.
However, MRONJ is a well-recognized adverse side effect of bisphosphonate (BP) therapy. Authors reported that according to the existing literature, the rate of MRONJ for patients taking intravenous BPs varies between 0.8 percent and 12 percent. When bisphosphonates are administered for the treatment of osteoporosis, the risk of developing MRONJ is 1 in 1,000,000 when the treatment is provided for less than three years. When the treatment is provided for more than three years the risk is 1 in 10,000.
Reporting on current evidence, authors said the mandible is affected twice as often as the maxilla and the route of administration (IV) and dento-alveolar procedures are main risk factors. They noted that the 2014 AAOMS position paper still recommends adopting a conservative approach and avoiding dental extractions or bone surgery in patients treated with IV BPs for oncological reasons.
However, dental extraction surgical protocols that seem to decrease the risk of MRONJ have been recently reported. To investigate MRONJ rates and contributing risk factors, scientists searched the databases of PubMed/MEDLINE, Embase and LILACS through June 4, 2014, to answer a focused question: “In patients treated with ARD, what is the occurrence rate and what are the risk indicators of MRONJ after dental extraction?” A secondary focus of their review was to potentially determine optimal surgical techniques for performing dental extractions in patients treated with BPs. A manual search for all potentially relevant research was also conducted.
Thirteen studies providing data on dental extractions performed in 2,662 patients treated with ARD were examined. Within the review, a total of 2,098 patients were treated for osteoporosis (79 percent) and 564 (21 percent) were treated with IV therapy for oncological reasons.
Ten studies reported on the occurrence of MRONJ after tooth extractions in patients receiving IV treatment for cancer. Among the 564 patients in the review, a total of 36 MRONJ cases (3.2 percent) were identified. Among them, when an alveolectomy was not the surgical treatment protocol, the occurrence of MRONJ reached 5.9 percent. Eight studies reported about the occurrence of MRONJ after tooth extraction in patients treated for osteoporosis. Of the 2,098 osteoporosis cases in the review, nine cases of MRONJ (0.15 percent) emerged.
Authors asserted within conclusions that the risk of MRONJ after dental extractions is rather low in patients treated with BPs for osteoporosis. They said that study results emphasize that where a risk of MRONJ in oncologic patients exists, it can be minimized when adjusted protocols involving alveolectomy or the use of a biological membrane are performed. They further stated, “Considering the potential associated characteristics for MRONJ development, additional caution might be suggested with certain patients, including those treated with zoledronate, patients with concomitant chemotherapy and patients displaying installed osteomyelitis.”
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Workshop proceedings and clinical applications are still available
Systematic reviews and consensus reports from the American Academy of Periodontology’s “Enhancing Periodontal Health Through Regenerative Approaches” workshop (which was held in Chicago in 2014) are available online from the Journal of Periodontology, and practical application reports — designed to guide clinicians in the regenerative treatment of advanced gum disease — are available in Clinical Advances in Periodontics, which also offers videos and illustrations detailing various clinical scenarios and outcomes.
Topics of the workshop include:
• Managing gingival recession based on current evidence with a primary outcome goal of complete root coverage.
• Assessing the need for gingival augmentation procedures (non-root coverage) around natural teeth.
• Periodontal regenerative strategies for the management of intrabony periodontal defects.
• Management of periodontal furcation defects via periodontal regenerative therapy and parameters for treatment selection.
• Emerging technologies for periodontal regeneration.
Each practical applications paper describes a specific clinical situation, approaches in its management and treatment decisions based on provided evidence.
To learn more about this workshop, click here.
How many of your patients lie about flossing?
Study says 27 percent
A national survey administered by the American Academy of Periodontology found that 27 percent of American adults lie to their dentists about how often they floss their teeth. The survey also found that instead of flossing 18 percent would prefer to wash dishes, 14 percent would rather wait in a long line, another 14 percent would choose to clean the toilet and 9 percent would prefer to sit in gridlock traffic. Learn more about Americans’ relationships with their gums by clicking here.
Everything your patients really need to know about perio disease
To inform patients about causes of periodontal disease and what lies ahead if disease is not treated, the ADA offers an all-in-one brochure. Periodontal Disease: Don’t Wait Until it Hurts helps practitioners explain cause and effect in a way patients remember clearly. The brochure features vivid illustrations of probing, SRP, and periodontal surgery, along with bone loss x-rays and “stages of perio” photos.
“Periodontal Disease” is a 12-page booklet sold in packs of 50. The brochure is also available in Spanish or personalized versions. To order, call 1-800-947-4746 or go to adacatalog.org. Readers who use the code 16404E before February 5 can save 15 percent on all ADA Catalog products.
Available for download
Clinical and scientific papers from the AAP
The American Academy of Periodontology has developed a suite of resources to be used as guidelines for dentists dealing with periodontal health issues. These resources include disease classifications, AAP-commissioned reviews, parameters of care, position papers, consensus papers/clinical recommendations and academy statements.
View and download these materials by clicking here.
What is Specialty Scan?
This is one in a series of quarterly newsletters updating dentists on selected specialties in dentistry. Information presented is aggregated and summarized from previously published materials, each item attributed to its publication of origin. This issue of JADA Specialty Scan focuses on Periodontics, the first in the series on this topic for 2016. Other Specialty Scan issues are devoted to endodontics, oral pathology, oral and maxillofacial radiology, orthodontics and prosthodontics. The ADA has engaged the specialty organizations in these areas as well as its own Science Institute and Division of Legal Affairs to assist with these newsletters. We welcome feedback on this and all Specialty Scan issues.
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