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Safety and Efficacy of Sub-Antimicrobial-Dose Doxycycline Therapy in Patients with Adult Periodontitis

The objectives of the studies presented here were to assess the safety and efficacy of the adjunctive administration of sub-antimicrobial-dose doxycycline (SDD) for the treatment of adult periodontitis and to confirm the optimal dosing regimen. The studies summarized included four double-blind, placebo-controlled, randomized clinical trials, conducted over a period of 9 to 12 months. Analysis of efficacy data demonstrated that adjunctive SDD treatment resulted in: (1) increases in clinical attachment levels; (2) decreases in probing pocket depths; and (3) reductions in bleeding on probing in patients with adult periodontitis. There were no significant adverse events or unwanted long-term antimicrobial effects associated with orally administered SDD. The results of these clinical trials indicate that the adjunctive use of SDD 20 mg BID is an effective and well-tolerated regimen which can significantly improve several indices of periodontal health.

Agents for the Management of Plaque and Gingivitis

Numerous chemical agents have been evaluated for the supplementation of patient-dependent mechanical plaque control and thus the reduction or prevention of oral diseases. Agents discussed in this paper are those most frequently evaluated in recent studies and include chlorhexidine, essential oils, triclosan, sanguinarine, fluorides, oxygenating agents, quaternary ammonium agents, prebrushing rinses, enzymes, and antibiotics. Of the agents discussed, the greatest effect on the reduction of plaque and gingivitis can be expected from chlorhexidine, essential oils, and triclosan-containing products. These chemical agents vary in dosage form and include mouthrinses, gels, and dentifrices. Some may also be of value as irrigants. Adverse effects vary according to the chemical agent and include poor taste, burning sensation of oral tissue, staining of teeth and soft tissues, excess supragingival calculus, oral lesions in young patients, and allergic reactions. When a product is selected for a patient, consideration should be given to necessity, efficacy, adverse effects, and cost-effectiveness.

Evaluation of dental extractions, suturing and INR on postoperative bleeding of patients maintained on oral anticoagulant therapy

Objectives To examine the consequences of temporary withdrawal of warfarin and/or suturing on bleeding and healing pattern following dental extractions.Methods Two hundred and fourteen patients on long-term oral anticoagulation (warfarin) therapy scheduled for dental extraction were randomly divided into four groups: no suturing and discontinued (group 1) or continued warfarin (group 2), and suturing and discontinued (group 3) or continued warfarin (group 4). International normalised ratio (INR) was determined at different time points (baseline, days 1, 3 and 7).Results Discontinuing warfarin reduced INR level significantly at day 1, which subsequently reached <1.5 in 96 out of 104 patients (group 1 and 3). Statistical comparisons among the different treatment groups did not reveal any significant difference regarding bleeding status or healing pattern. Interestingly, patients who received sutures showed higher but insignificant incidence of bleeding postoperatively compared to their respective controls.Conclusion Dental extractions may be safely performed for patients on anticoagulation therapy provided the INR level is kept <3.0 and effective measures of local haemostasis are administered. The decision to suture should be made on case-by-case basis, as the trauma associated with soft tissue handling might outweigh its advantages in certain situations like simple extractions.

Metabolomics Reveals Elevated Macromolecular Degradation in Periodontal Disease

Periodontitis is a chronic inflammatory disease characterized by tissue destruction. In the diseased oral environment, saliva has primarily been considered to act as a protectant by lubricating the tissue, mineralizing the bones, neutralizing the pH, and combating microbes. To understand the metabolic role that saliva plays in the diseased state, we performed untargeted metabolomic profiling of saliva from healthy and periodontitic individuals. Several classes of biochemicals, including dipeptide, amino acid, carbohydrate, lipids, and nucleotide metabolites, were altered, consistent with increased macromolecular degradation of proteins, triacylglycerol, glycerolphospholipids, polysaccharides, and polynucleotides in the individuals with periodontal disease. These changes partially reflected the enhanced host-bacterial interactions in the diseased state as supported by increased levels of bacterially modified amino acids and creatine metabolite. More importantly, the increased lipase, protease, and glycosidase activities associated with periodontitis generated a more favorable energy environment for oral bacteria, potentially exacerbating the disease state.

The Effect of Doxycycline Hyclate, Chlorhexidine Gluconate, and Minocycline Hydrochloride on Osteoblastic Proliferation and Differentiation In Vitro

BACKGROUND The purpose of this study was to determine the effect of the active substance of three types of local delivery systems, doxycycline hyclate 10% (DOXY), chlorhexidine gluconate, 2.5 mg (CHX), and minocycline hydrochloride, 1 mg (MINO), on osteoblastic cell proliferation and differentiation. METHODS There were four groups: control osteoblastic cells (OB) alone, OB + DOXY, OB + CHX, and OB + MINO. Trypan blue and MTT [3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide] assays were used to test osteoblastic cell viability. Cell differentiation was tested by measuring alkaline phosphatase levels. Osteoblast morphology was investigated by light and scanning electron microscopy. RESULTS At a concentration of 0.5 mg/ml, the Trypan blue test showed that DOXY, MINO, and CHX had significant toxicity effects on osteoblast cells compared to the control group, with a mean cell viability of 84%, 74%, and 51%, respectively (P <0.05). The MTT test showed that the control and DOXY groups were statistically significantly different (P <0.05) compared to CHX and MINO groups. The DOXY group showed a significantly higher alkaline phosphatase activity ( approximately 56%) than the control and MINO groups, and it was nearly 178% higher than the CHX group (P <0.05). The morphology of the osteoblasts seemed to be slightly altered when they were incubated with DOXY; however, with MINO, they appeared rounded with minimal attachment. In the CHX group, the osteoblasts assumed a shape of a very thin filopodia with a volcano-like nucleus. CONCLUSIONS At a concentration of 0.5 mg/ml, CHX and, to a lesser extent, MINO had a cytotoxic effect on osteoblast proliferation in vitro. However, DOXY seemed to enhance maturation and differentiation rather than proliferation. In addition to DOXYs beneficial effect as an adjunctive therapy to mechanical debridement in the treatment of periodontal disease, it may have an effect on periodontal regeneration.

Thromboembolic risk and bleeding in patients maintaining or stopping oral anticoagulant therapy during dental extraction

thromboembolism (12%), heart valvulopathy (10%), and other indications (3%). All the procedures were carried out by the same oral surgeon. Before undertaking 511 dental extractions (in average four teeth per patient), six fixture insertions and six exeresis of cystic neoformations, patients were randomized to two treatment groups. In group A (mean age 64 ± 11 years), OAT dosage was reduced during the 72 h before surgery to attain INR values between 1.5 and 2.0 (target 1.8) on the day of surgery. The mean INR value actually attained in this group was 1.77 ± 0.26. In group B (mean age 61 ± 12 years), OAT dosage was not reduced, but hemostatic agents such as tranexamic acid, oxidized cellulose or collagen sponges were applied on the surgically treated region. The mean INR measured in this group was 2.89 ± 0.42 on the day of surgery. After 2 h of postsurgical observation, all patients were discharged and received written instructions to avoid nonsteroidal anti-inflammatory drugs (only paracetamol was allowed), to record the length and severity of any bleeding and to contact the center immediately in case of bleeding not controlled by compression for 20 min. Patients in group A were required to restore oral anticoagulant treatment to return to their regular INR on the day after the procedure, while those of group B were asked to continue their regular dosage. All patients were summoned 7 days after the procedure for the removal of the sutures. During this examination, the presence or absence of late bleeding was also recorded. Only patients in group B (OAT not reduced) were instructed to perform mouthwashing with tranexamic acid at home (10 mL for 2 min, four times daily, for 6 days after procedure), and a daily telephonic contact by a nurse was arranged for 6 days after the procedure. Bleeding was considered as an ‘event’ if any intervention by the surgeon was needed to stop it either with a new suture or with placement of other local hemostatic agents. Bleeding successfully managed at home by patients were not considered an event. Bleeding excessive enough to warrant adoption of supplementary local hemostatic measures was observed, in 10 cases (15.1%) in group A (reduced dosage) and in six (9.2%) in group B (unmodified dosage). Bleeding, irrespective of the group, was treated with the insertion of oxidized cellulose inside the procedural area. There was no thrombotic complication in these patients. This randomized study shows that, using simple and inexpensive measures for local hemostasis, it is not necessary to reduce OAT intensity in patients undergoing oral surgery. The adoption of this procedure may prevent thromboembolic complications associated with subtherapeutic INR values.

In vitro and in situ transfer of local anaesthetics across the oral mucosa

Abstract The rates of transfer of C14-labelled lidocaine and prilocaine through the frenulum of the tongue of the dog were studied in vitro and in situ. Tenfold increases of the local anaesthetic concentration on the outside of the frenulum increased the rate the radioactivity was transferred to the inside by tenfold in the in vitro preparation. In situ, a doubling of the local anaesthetic concentration resulted in a greater than twofold increase in transfer rate. The transfer of local anaesthetic both in vitro and in situ increased as the pH of the applied local anaesthetic solution increased. Incorporation of 1 per cent cetylpyridinium chloride into the local anaesthetic solution in vitro could either increase or decrease the transfer of local anaesthetic. When 0.1 or 0.01 per cent cetylpyridinium chloride was added to the local anaesthetic solution in situ, the rate of local anaesthetic transfer was increased. The similarity between transfer of local anaesthetics across the frenulum of the tongue and transfer across lipoid membrane is discussed.

The prevalence of oral Candida infections in periodontitis patients with type 2 diabetes mellitus.

OBJECTIVES The purpose of this study was to determine the prevalence of Candida spp. in periodontitis patients with type 2 diabetes mellitus. METHODS This cross-sectional study included 42 diabetic patients with periodontitis (aged 21-70 years; 18 males and 24 females). Clinical measurements included probing pocket depth (PPD), clinical attachment level (CAL) and hemoglobin A1c (HbA1c) levels. Sub-gingival samples were collected from the mesio-buccal aspect of 3 teeth for fungal analysis. Candida species, including Candida albicans, Candida dubliniensis, Candida tropicalis and Candida glabrata, were identified using Gram staining, the germ tube test, CHROMagar, Staib agar and API 20C AUX. RESULTS The overall prevalence of Candida in diabetic patients with periodontitis observed in our study was 52%. The most common spp. of Candida identified were C. albicans (38%), followed by C. dubliniensis (9.5%), C. tropicalis (4.7%) and C. glabrata (4.7%). Compared to females, male patients were characterized by increased levels of Candida infections. Our results also indicate that individuals over the age of 40 had increased levels of Candida infections compared to patients younger than 40. Candida infections were higher among subjects with elevated blood sugar levels (HbA1c>9) compared to individuals with well-controlled blood sugar levels (HbA1c<6). Patients with PPDs≥5 had an increased risk of Candida infection compared to patients with PPDs between 3 and 4. CONCLUSION This study indicates that the frequency of C. albicans is higher than the frequencies of C. dubliniensis, C. tropicalis and C. glabrata in diabetic patients with periodontitis. Candida infections were observed at increased frequencies among subjects with high blood sugar levels and PPDs≥5.

The effect of an 810-nm diode laser on postoperative pain and tissue response after modified Widman flap surgery: a pilot study in humans.

BACKGROUND The purpose of this single-masked pilot clinical study is to compare the tissue response and postoperative pain after the use of a diode laser (810 nm) (DL) as an adjunct to modified Widman flap (MWF) surgery to that of MWF alone. METHODS Thirteen patients with generalized severe chronic periodontitis completed the study. Control sites were randomly selected to receive an MWF and the contralateral test sites an MWF in conjunction with a DL. The study tooth/site was treated plus any additional teeth in the quadrant in which the site was located, if needed. Randomization was done using a coin flip. The DL was used to de-epithelialize the inner part of the periodontal flap and photo-biostimulate the surgical area. Pain scale assessment (PS), pain medication consumption (PM), tissue edema (TE), and tissue color (TC) were evaluated 1 week after surgery. RESULTS Statistically significant differences were seen for TE (P = 0.041), PM (P <0.001), and PS (P <0.001) favoring test sites. TC did not show a statistically significant difference (P = 0.9766). Patients rated the first surgical treatment (test or control; random assignment to first treatment) performed as more painful than the second (P <0.002). CONCLUSION The use of an 810-nm diode laser provided additional benefits to MWF surgery in terms of less edema and postoperative pain.

Expanded and Future Uses of Mouthrinses

The use of antimicrobial mouthrinses is important to dental professionals and their patients. Listerine Antiseptic was found to greatly decrease the anaerobic and aerobic bacteria associated with bacteremia, when used as a subgingival irrigant prior to scaling. Furthermore, preprocedural rinsing with either Listerine or chlorhexidine gluconate (Peridex) can greatly decrease the number of bacteria aerosolized during many dental procedures. Studies have shown that both Listerine and chlorhexidine have anti-Candida properties and therefore are helpful to patients who are immunosuppressed and subject to the opportunistic infection of candidiasis. Chlorhexidine has also been shown to decrease the incidence and severity of mucositis during cancer chemotherapy. Healing of the wounds and aiding in plaque control following periodontal surgery are further benefits of chlorhexidine and Listerine. Finally, each of these antimicrobials can be adjuncts to implant maintenance.