Non-surgical periodontal therapy: An update on current evidence Rahul s bhansali citation



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P- Reviewer: Abundo R, Haraszthy V, Mishra AK S- Editor: Song XX L- Editor: A E- Editor: Lu YJ


Table 1 Summary of the systematic reviews for mechanical non surgical periodontal therapy

Systematic review


No. of studies


Treatment modalities


Tested clinical parameters


Conclusion


Mechanical therapy


Tunkel et al[17]


27


Machine driven vs subgingival debridement


Tooth loss, CAL, PPD, BOP


No difference between ultrasonic/sonic and manual debridement in the treatment of chronic periodontitis for single-rooted teeth. Ultrasonic/sonic subgingival debridement requires less time than hand instrumentation


Van der Weijden et al[25]


26


Subginigval debridement + supragingival plaque control


BOP, PPD, CAL


Improvement in PPD and CAL by subgingival debridement (with supragingival plaque control)


Slots et al[19]


15


Vector® ultrasonic scaler vs conventional ultrasonic instruments and/or hand instrumentation


Calculus removal, time of instrumentation, root surface aspects, patients' perception, BOP, PPD, CAL and microbiological effects


Comparable clinical and microbiological effect of all 3 modalities. Vector® ultrasonic system is more time consuming


Laser therapy














Schwarz et al[29]


11


Laser monotherapy vs mechanical debidement


Clinical data

Laser safety data



Er:YAG laser monotherapy resulted in similar clinical outcomes, both in the short and long term compared with mechanical debridement. Insufficient evidence to support the clinical application of either CO(2), Nd:YAG, Nd:YAP, or different diode lasers


Karlsson et al[32]


4


Laser therapy + SRP


BOP, PPD, CAL


No consistent evidence for efficacy of laser as an adjunct to NSPT in adults with chronic periodontitis


Slots et al[30]


8


Nd:YAG Laser monotherapy vs Laser + SRP


Plaque, BOP, gingivitis, PPD, CAL, and GR


No beneficial effect of a pulsed Nd:YAG laser compared to ultrasonics and/or hand instrumentation in the initial periodontitis


Sgolastra et al[31]


5


Er:YAG laser vs SRP


CAL, PPD and GR


No evidence of effectiveness of Er:YAG laser compared to SRP


Photodynamic therapy


Azarpazhooh et al[40]


5


Monotherapy or adjunctive PDT


PPD, CAL, GR, Full mouth plaque and bleeding scores


Routine use of PDT for clinical management of periodontitis cannot be recommended


Sgolastra et al[39]


4


PDT used alone or adjunctive to scaling root planning


CAL, PPD, GR


PDT adjunctive to conventional treatment provides short-term benefits, but microbiological outcomes are contradictory. No evidence of effectiveness for the use of PDT as alternative to SRP


CA: Clinical attachment level; PPD: Probing pocket depth; BOP: Bleeding on probing; SRP: Scaling and root planing; GR: Gingival recession; PDT: Photodynamic therapy; Er:YAG: Erbium-doped: yttrium-aluminum garnet; Nd:YAG: Neodinium doped: yttrium-aluminum garnet.


Table 2 Summary of systematic reviews on adjunctive chemothrerapeutic agents

Systematic review


No. of studies


Treatment modalities


Tested clinical parameters


Conclusion


Systemic antimicrobial therapy


Herrera et al[50]


25


SRP + systemic antibiotics vs SRP alone or SRP + placebo


PPD, CAL


Systemic antimicrobials in conjunction with SRP can offer an additional benefit over SRP alone in the treatment of periodontitis


Haffajee et al[51]


29


SRP + systemic antibiotics vs SRP alone or SRP+ placebo


CAL


The use of systemically administered adjunctive antibiotics with and without SRP and/or surgery appeared to provide a greater clinical improvement in CAL


Goodson et al[52]


RCT# (187 Patients)


SRP + systemic antibiotics vs SRP + local antibiotic therapy and/or periodontal surgery


CAL, PPD


Adjunctive therapies generally exhibited improved CAL gain and/or PPD reduction when compared with SRP alone


Sgolastra et al[54]


6


AMX/MET + SRP vs full mouth SRP alone


CAL, PPD, secondary outcomes, and adverse events


Significant CAL gain and PPD reduction in favor of full mouth SRP + AMX/MET; no significant risk difference in the occurrence of adverse events


Sgolastra et al[55]


4


AMX/MET + SRP vs SRP alone


CAL, PPD, secondary outcomes, and adverse events


Significant CAL gain and PPD reduction in favor of SRP + AMX/MET; no significant difference in BOP or suppuration. Supports effectiveness of SRP with AMX/MET in chronic periodontitis


Zandbergen et al[53]


28


Adjuvant AMX/MET + SRP


CAL, PPD, plaque index, BOP


AMX/MET as an adjunct to SRP can enhance the clinical benefits of non-surgical periodontal therapy in adults who are otherwise healthy


Keestra et al[56]


43


Different systemic antibiotics + SRP vs SRP alone


BOP, CAL, PPD


Systemic antibiotics combined with SRP offer additional clinical improvements compared to SRP alone. For initially moderate and deep pockets, MET or MET + AMX, resulted in clinical improvements that were more pronounced over doxycycline or azithromycin. Clinical benefit became smaller over time (1 yr)


Local antimicrobial therapy


Hanes et al[60]


32


Local controlled-release anti-infective drug therapy with or without SRP vs SRP alone


PPD, CAL


Local anti-infective agents resulted in significant adjunctive PPD reduction or CAL gain for minocycline gel, microencapsulated minocycline, CHX chip and doxycycline gel during SRP compared to SRP alone. The decision to use local anti-infective adjunctive therapy remains a matter of individual clinical judgment, the phase of treatment, and the patient’s status and preferences


Bonito et al[61]


3


Local antimicrobials with SRP vs SRP alone


CAL, PPD


Only modest improvements in PPD reductions


Matesanz-Pérez et al[62]


52


Local antimicrobials with SRP vs SRP alone


CAL, PPD, plaque index, BOP


Scientific evidence supports the adjunctive use of local antimicrobials to debridement in deep or recurrent periodontal sites, mostly when using vehicles with proven sustained release of the antimicrobial


Full mouth disinfection


Eberhard et al[78]


7


FMD with or without antiseptics vs quadrant scaling


Tooth loss, BOP, PPD, CAL


Only minor differences in treatment effects between the treatment strategies


Eberhard et al[79]


7


FMD with or without antiseptics vs quadrant scaling


Tooth loss, BOP, PPD, CAL


Slightly more favourable, but modest outcomes were found following FMD in moderately deep pockets. Very limited number of studies available for comparison, thus limiting general conclusions about the clinical benefit of full-mouth disinfection


Lang et al[80]


12


FMD with or without antiseptics vs conventional staged debridement


BOP, PPD, CAL microbial changes


Despite the significant differences of modest magnitude, FMD with or without antiseptics do not provide clinically relevant advantages over conventional staged debridement. Hence, all three treatment modalities may be recommended for debridement in the initial treatment of chronic periodontitis


Farman et al[81]


7


Full mouth debridement vs FMD with antiseptics vs quadrant scaling


BOP, PPD, CAL


Traditional quadrant approach and full-mouth debridement could be equally effective


CAL: Clinical attachment level; PPD: Probing pocket depth; SRP: Scaling and root planing; BOP: Bleeding on probing; RCT: Randomized controlled clinical trial; AMX/MET: Amoxicillin plus metronidazole; FMD: Full mouth disinfection.



Table 3 Recommended systemic antibiotic dosing regimens

Single agent regimen dosage/duration





Amoxicillin


500 mg, three times per day × 8 d


Azithromycin


500 mg, once daily × 4-7 d


Ciprofloxacin


500 mg, twice daily × 8 d


Clindamycin


300 mg, three times daily × 10 d


Doxycycline or minocycline


100-200 mg, once daily × 21 d


Metronidazole


500 mg, three times daily × 8 d


Combination therapy





Metronidazole + amoxicillin


250 mg, of each three times daily × 8 d


Metronidazole + ciprofloxacin


500 mg of each twice daily × 8 d


Adapted from Krayer et al[41].



Table 4 Summary of systematic reviews on host modulation therapy

Systematic review


No. of studies


Treatment modalities


Tested clinical parameters


Conclusion


Reddy et al[89]


7 (SDD), 10 (NSAIDs), 3 (BPs)


Adjuntive efficacy of anti-proteinases, anti-inflammatory agents, and anti-resorptive


Bone changes, CAL, PPD, plaque index, gingivitis


Use of SDD+ SRP‡ is statistically more effective than SRP alone in reducing PPD and achieving CAL gain

Insufficient data for NSAIDs and BPs may have potential adjunctive role in periodontal therapy



Preshaw et al[92]


2


SDD + SRP vs SRP + placebo


CAL, PPD


Adjunctive SDD enhances therapeutic outcomes compared with SRP alone, resulting in clinical benefit in both smokers and non-smokers with chronic periodontitis


Sgolastra et al[91]


3


SDD + SRP vs SRP + placebo


CAL, PPD, Plaque Index, Gingival Index, and gingival crevicular fluid levels


Supports long-term effectiveness of adjunctive SDD therapy


Moreno Villagrana et al[90]


9


SDD + SRP vs SRP + placebo


CAL, PPD


Statistically significant results in patients with aggressive or chronic periodontitis under periodontal treatment


SDD: Subantimicrobial dose doxycycline; NSAID: Non steroidal antiinflammatory drug; BP: Bisphosphonates; CAL: Clinical attachment level; PPD: Probing pocket depth; SRP: Scaling and root planing.


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