Benefits, risks of adjunctive antimicrobial therapy with scaling and root planing in patients with diabetes
Adjunctive therapy may improve the efficacy of scaling and root planing (SRP) to reduce probing depth in patients with diabetes, but the protection offered by antibiotics and small gains in probing depths should be weighed against the potential for antibiotic resistance and other side effects.
Those 2 findings are part of research published online March 18 in Journal of Clinical Periodontology.
Researchers conducted a review of 13 randomized clinical trials to determine whether treatment with antibiotics as an adjunct to SRP improves periodontal outcomes in participants with diabetes who have periodontitis.
Researchers used 4 inclusion criteria for the studies: a clinical trial, an examination of participants with diabetes who have periodontitis, the use of SRP with the use of a systemic antimicrobial drug, and a comparison of the use of SRP alone and SRP with placebo. All of the studies were parallel, randomized clinical trials. Follow-up periods ranged from 3 to 12 months. Seven studies excluded smokers, and 2 included smokers. The remaining 4 did not report smoking status.
Data analyses were performed according to the Cochrane statistical guidelines. Meta-analyses were performed on primary and secondary outcomes to compare the response to therapy between the intervention and control groups.
Test and control interventions were performed as full-mouth or conventional quadrant treatments. The authors of some articles reported on the duration of mechanical therapy, which ranged from 1 to 8 sessions conducted between less than 1 day to 2 weeks.
Baseline weighted mean differences did not differ significantly for probing depth (PD) and clinical attachment level (CAL). But end-of-trial PD and CAL showed statistically significant differences in reduction between the test and control groups.
Global meta-analyses showed no statistically significant differences in CAL gain between treatment groups but did show a statistically significant difference in PD reduction, favoring adjunctive systemic antibiotic therapy over SRP alone. Still, researchers warned that systemic antibiotic use could lead to long-term bacterial resistance.
“Resistance and other unwanted side effects of antibiotics should be balanced against the positive effects of these drugs,” the researchers wrote in the discussion. “Their prescription should be considered on a case-by-case basis and limited in clinical situations in which the risks need to be clearly offset by benefits to the patient.”
Research limitations were that just 2 studies included 9- to 12-month follow-up periods, and only 2 studies including participants who smoked. Studies using any antibiotic type, dosage, and regimen were included. As a result of this heterogeneity of included studies, the researchers noted an obvious lack of consensus on optimal dosage.
Read the original study.
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
Do connective-tissue graft, collagen matrix enhance wound stability?
Suturing a connective-tissue graft (CTG) to a nonshedding hard surface in dogs greatly increases flap resistance to tearing when applying disruptive forces.
That’s the key finding of research published in the April issue of Journal of Clinical Periodontology.
In the study, researchers set out to measure whether interpositioned CTG or a xenogeneic collagen matrix (CM) mechanically improved flap stability after mucosal coverage of bone dehiscence defects.
Researchers chose 5 Beagles that were at least 1 year old for the study. Two weeks before surgery, the dogs’ teeth were cleaned with toothbrushes and dentifrice daily, 5 days per week. Dogs were kept in individual cages on a hard soil run, with free access to soft food and water.
Researchers identified 12 sites per dog for defect preparation. Vertical incisions of 15 millimeters were placed in the maxillary and mandibular arches using a double-bladed scalpel with blades mounted 8 mm apart. Full-thickness flaps were elevated beyond the mucogingival junction and bone dehiscence defects of 8 x 8 mm were created by removing the buccal bone and scaling the root surfaces.
Researchers harvested 1 CTG from the palatal area as a free masticatory composite mucosal graft. The graft’s epithelial layer was removed extraorally with a sharp blade, and the graft was thinned to a thickness of less than 1 mm. The piece of connective tissue was further trimmed into 4 grafts of 8 x 8 mm each corresponding to the dimensions of the bone dehiscences. Palatal wounds were then sutured to the denuded donor area.
On days 1, 3, 7, and 14 after surgery, the dogs were anesthetized, and their sutures removed. The releasing incisions were retraced in the visible incision lines or scar formations with a surgical blade. A force directed in the long axis of the teeth was applied to the flaps to measure adherence strength. Progressive force was applied until the flaps were completely separated from the underlying wound beds.
Researchers found that sites belonging to the CTG group had the highest amount of wound strength between days 3 and 7. After an initial healing phase of 3 days, forces for the flap disruption in the CTG group were significantly higher than those of the control group.
“[T]he interface between a debrided, non-shedding surface and the mucoperiosteal flap was less resistant to tensile forces than a comparative interface between a flap and connective tissue layer or a collagen mix firmly affixed to a denuded root surface,” the researchers concluded. “Obviously, the interpositioning of a CTG or CM improved wound strength.”
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AAP 2017 Annual Meeting in Boston: register now and set the early-bird rate!
Mark your calendars! The 103rd Annual Meeting of the American Academy of Periodontology will be held Sept. 9-12, 2017, in Boston.
For more information, e-mail email@example.com.
Periodontitis and metabolic syndrome association eyed
Periodontitis is associated with metabolic syndrome (MetS), and the prevalence of MetS is related to severe periodontitis, according to research published in the April issue of Journal of Periodontology.
The research incorporates several definitions of periodontitis and MetS, and provides a substantially larger sample size to determine whether an association between the severity of periodontal breakdown and MetS exists.
Researchers conducted a cross-sectional study of 419 adults recruited from the Diabetes and Hypertensive Treatment Center in Feira de Santana, Bahia, Brazil, from June 2013 through February 2014. Inclusion criteria included that participants be at least 24 years old, have at least 4 teeth to ensure measurements necessary to diagnose a periodontal condition, and have laboratory measurements for triglycerides, high-density lipoprotein (HDL) cholesterol, and fasting glucose obtained in the previous 90 days.
Laboratory results were collected for the following 11 measurements: triglycerides, HDL cholesterol, fasting glucose, total cholesterol, low-density lipoprotein cholesterol, creatinine, uric acid, microalbuminuria, leukocytes, band cells, and neutrophils. A single examiner reviewed the medical histories and conducted physical examinations of all participants.
A single dentist masked to the participants’ medical statuses conducted oral clinical examinations to assess the presence of teeth, caries, and restorations. Periodontal status was examined on all teeth except third molars.
Participants were diagnosed as having periodontitis if they had at least 4 teeth with at least 1 site with a probing depth of at least 4 millimeters, a clinical attachment level of at least 3 mm, and bleeding on probing at the same site. Participants were classified as having severe periodontitis if they had at least 2 interproximal sites with a clinical attachment level of at least 6 mm and at least 1 interproximal site with a probing depth of at least 5 mm.
To be diagnosed with MetS, participants had to have at least 3 of the following criteria—abdominal obesity, hypertension, diabetes mellitus, increased triglyceride levels, or decreased HDL cholesterol.
Researchers diagnosed 255 of the 419 participants with MetS according to The National Cholesterol Education Program criteria and 281 participants according to International Diabetes Federation criteria. The prevalence of periodontitis ranged from 34.6% to 55.4%, depending on the classification definitions used. In the group with periodontitis, levels were severe in about 14.1% of participants. The adjusted measurement for the association between severe periodontitis and MetS showed MetS to be 2.1 times more prevalent in the group with periodontal infections than in the nonperiodontitis group after adjustment.
“Periodontitis may predispose individuals to MetS through mechanisms triggered by the translocation of oral bacteria and/or their products into the blood circulation,” the authors wrote in the discussion. “These bacteria may then provoke immune and inflammatory processes that initiate or exacerbate MetS.”
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Patients’ pain perception assessed after surgical procedures
Most patients who undergo periodontal surgery perceive mild postoperative pain, but those levels vary among surgical procedures. Periodontal plastic surgery, complex surgery, extension of surgery, and the amount of anesthetic used are more likely to be associated with moderate to severe postsurgical pain.
Those findings are part of research published online August 24 in Journal of Clinical Periodontology.
Researchers evaluated 330 surgeries in 253 patients who were scheduled for periodontal or implant-related surgeries at the Department of Periodontics, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan, from July 2012 through July 2013. Researchers grouped 10 surgical types into 3 surgical categories: simple surgery (open flap debridement, implant stage II, straight-forward implant), complex surgery (osseous resective, periodontal regeneration, bone augmentation, advanced implant, peri-implantitis), and periodontal plastic surgery (gingivectomy, soft-tissue augmentation).
All surgical procedures were performed by 1 of 3 authors: a resident with 2 years of periodontal training and 2 experienced periodontists. All surgical procedures followed standard protocols under local anesthetic, and standard postsurgical instructions were given. Patients were instructed to take analgesics as needed for pain control and to continue mouthrinse for 7 days. An antibiotic was prescribed according to the surgeon’s decision.
On the seventh day after surgery, patients were recalled for inspection or removal of sutures and instructed to specify a number that represented the intensity of the worst pain level experienced in the past week. Perception of pain was measured on a scale of 1 through 10, in which scores of 1 through 3 indicated mild pain, 4 through 6 indicated moderate pain, and 7 through 10 indicated severe pain.
A total of 232 patients reported mild pain, 84 reported moderate pain, and 14 reported severe pain. The highest numeric rating score was found in patients who underwent advanced implant surgery. The lowest pain score was found in those who underwent open flap debridement surgery. The pain scores of those who underwent simple surgery were significantly different from those who underwent complex surgery.
Researchers also found that patients reporting severe pain had a longer duration of surgery, a more extensive surgical site, and a greater amount of local anesthetic than those reporting mild pain. Patients who underwent complex surgery were 2.6 times more likely to experience severe pain than those who underwent simple surgery, and patients who underwent periodontal surgery were 3.2 times more likely to experience severe pain.
Patients were 78% more likely to experience severe pain when the surgical site was extended by more than 1 tooth and were 2 times more likely to experience severe pain when 1 more carpule of local anesthetic was used. Patients were 3.5 times more likely to experience severe pain when both variables increased by 1 unit at the same time.
This study, and further research into this area may help provide relevant knowledge to the clinician in terms of being able to predict analgesic needs among surgical patients.
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Periodontal disease experts: floss or risk losing your teeth
Although a recent report from the Associated Press found much of the research behind flossing's effectiveness on oral health to be weak or unreliable, periodontists agree that keeping the spaces between your teeth clean is paramount in ensuring healthy teeth and gingivae.
Click here to read more.
Have your patients seen Gumblr?
As the online destination for Love The Gums You’re With, the AAP’s consumer awareness campaign, Gumblr.org offers various creative and informative assets designed to educate the public on the value of gingival health. With interactive quizzes, videos, and articles, as well as an array of periodontal care tips, Gumblr is a fun way for patients to learn why it’s important to love their gingiva for life. Share it with your patients—Gumblr.org.
New ADA periodontal disease brochure educates patients
“Periodontal Disease: Your Complete Guide” is a new and comprehensive booklet that covers every important aspect of periodontal disease, including prevention, detection, treatment options, and maintenance. Its content reinforces that proper oral hygiene, diet, and regular dental visits can help minimize risk.
The booklet includes dedicated space to add personal treatment plans for the patient; it also features photos of before and after deep cleaning and images of disease progression from healthy gingivae to advanced periodontitis. The 16-page booklet is sold in packs of 50 from the ADA Catalog. To order, call 1-800-947-4746 or go to adacatalog.org. Readers who use the code 16404E before November 4 can save 15% 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 fourth 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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