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J Clin Exp Dent. 2011;3(5):e424-9. Non surgical management of chronic periodontitis.
Journal section: Periodontology Publication Types: Research Non-surgical management of chronic periodontitis
with two local drug delivery agents- A comparative study.
Jaspreet Singh Gill 1, Vipin Bharti 2, Harinder Gupta 3, Sharanjeet Gill 4
1 BDS, MDS. Senior Lecturer, Department of Periodontics and Implantology, SGT Dental College, Hospital and Research Institu- te, Gurgaon, Haryana, India.
2 BDS, MDS. Prof & HOD, Department of Periodontics , Government Dental College, Patiala, Punjab, India.
3 BDS, MDS. Prof & HOD, Department of Periodontics , Government Dental College, Amritsar, Punjab, India.
4 BDS, MDS. Senior Lecturer, Department of Oral Pathology, Manav Rachna Dental College, Faridabad, Haryana, India.
Correspondence: Department of Periodontics, SGT Dental College, Hospital and Research institute, gurgaon. Haryana. E-mail address: drjaspreet13137@yahoo.com Gill JS, Bharti V, Gupta H, Gill S. Non-surgical management of chronic periodontitis with two local drug delivery agents- A comparative study. J Clin Exp Dent. 2011;3(5):e424-9.
Received: 18/01/2011 Accepted: 10/07/2011 Article Number: 50490 http://www.medicinaoral.com/odo/indice.htm Medicina Oral S. L. C.I.F. B 96689336 - eISSN: 1989-5488 Abstract
Background: The selective removal or inhibition of pathogenic microbes with locally delivered antimicrobials when combined with scaling and root planing is often an effective approach for the managment of chronic perio- Aim: To compare the clinical efficacy of tetracycline fibers and a xanthan based chlorhexidine gel in the treatment of chronic periodontitis.
Methods and materials: Thirty systemically healthy patients in the age group of 30-50 years suffering from genera- lized chronic moderate periodontitis were selected. For each subject, two experimental sites were chosen that had probing depth >5mm and were located in symmetric quadrants and the sites were randomized at split mouth level with one receiving tetracycline fibers and the other chlorhexidine gel. Plaque score, bleeding score, probing pocket depth and relative attachment level gain was recorded on day 0 and at the end of 3 months. Results and conclusion: In both groups, there was statistically highly significant reduction in all the clinical para- meters i.e. plaque score, bleeding score and probing pocket depth and relative attachment level gain was seen at di- fferent time intervals. Local delivery of tetracycline and chlorhexidine is a safe, easy and efficacious method along with scaling and root planing in the treatment of chronic periodontitis. Inter-comparison of both local drug delivery agents with respect to clinical changes shows that tetracycline fibers are better than chlorhexidine gel for treatment of chronic periodontitis. Nevertheless, long term studies with more samples are suggested to further evaluate and compare the efficacy of both materials. Key Words: local delivery, periodontitis, tetracycline fibers, chlorhexidine gel.


J Clin Exp Dent. 2011;3(5):e424-9. Non surgical management of chronic periodontitis.
cal drug delivery in various formulations such as mouth Periodontal diseases represent a group of localized mi- rinses, gels, sprays, varnishes, chips and subgingival crobial induced infections involving gingiva and suppor- irrigation devices (13-15).Chlorhexidine in form of gel ting tissues of the teeth. The role of microorganisms in has been used in varying concentrations such as 0.2%, the etiology and progression of periodontitis is now well 1% and 2% (13-15). In the present study, xanthan based documented (1). Periodontal diseases are routinely trea- 1.5% chlorhexidine gel was used as an adjunct to scaling ted by mechanical procedures which include meticulous and root planing .The aim of the present study was to scaling and root planing in conjunction with patient's compare the efficacy of tetracycline fibers (Periodontal proper plaque control. Although mechanical therapy Plus AB®) and chlorhexidine gel (Chlosite®) when used may provide long term stability for many patients, but as an adjunct to scaling and root planing in the manage- it fails to eliminate the pathogenic bacteria completely ment of chronic periodontitis. and may not always result in complete elimination of the disease (2). Material and Methods
Local delivery of antimicrobial agents into periodontal Thirty systemically healthy patients in the age group of 30- pocket has been extensively developed and investiga- 50 years (both male and female) suffering from generali- ted since late 1970's (3). Local delivery of antimicro- zed chronic moderate periodontitis were selected amongst bial agents includes oral rinses, subgingival irrigation the patients visiting the Department of Periodontics, Govt. and controlled release delivery systems (4). Controlled Dental College and Hospital, Patiala (Punjab). Patients release systems have received great interest and appear did not receive any surgical or non surgical periodontal to hold some promise in periodontal therapy. They have therapy in past 6 months and were not on any antibiotic been evaluated in several forms such as gels, strips, fi- therapy since past 3 months. Written informed consent bers, chips, ointments etc and using different antimicro- was taken from each patient who participated in the stu- bial agents such as tetracycline, doxycycline, metronida- dy and ethical clearance was obtained from the institutio- zole, minocycline and chlorhexidine (5-10). Pioneering nal committee. For each subject, two experimental sites work by Goodson introduced the use of tetracycline as were chosen that had probing depth >5mm and were lo- a local drug delivery agent for the treatment of perio- cated in symmetric quadrants and after scaling and root dontal diseases (11). He and his coworkers developed a planing, the two sites were randomized at split mouth local drug delivery system consisting of a polymer and level by flip of a coin and divided into two groups: ethylene vinyl acetate impregnated with 25% tetracycli- Group I: Tetracycline fibers (Periodontal Plus AB®) ne hydrochloride. One such local drug delivery system were inserted into the periodontal pocket until pocket is available in the form of resorbable tetracycline fibers was filled. Coe pak® was then applied for 10 days. (Fi- (Periodontal Plus AB®) Chlorhexidine is also a highly effective antimicrobial Group II: After washing the selected site with distilled agent that has been extensively studied and shown to be water and drying it, chlorhexidine gel (Chlosite®) was effective as a mouthrinse against supragingival plaque applied directly from the syringe into the pocket. Coe bacteria in prevention of gingivitis and as a treatment pak® was then applied for 10 days. (Figure 2) for gingivitis (12) .Chlorhexidine has been used for lo- Recording of various clinical parameters was carried on Fig. 1. Showing Periodontal Plus AB® fibers and insertion of fibres into the periodontal pocket


J Clin Exp Dent. 2011;3(5):e424-9. Non surgical management of chronic periodontitis.
Fig. 2. Showing Chlosite® gel and insertion of gel into the periodontal pocket day 0 (baseline) and subsequently recording of plaque chlorhexidine dihydrochloride. Xanthan is an optimum score and bleeding score was made at the end of 1 month substrate for the formation of a stable gel that is easily and 3 months, while probing pocket depth and relative extruded from a syringe needle. attachment level was recorded on day 0 and at the end # Periodontal Plus AB®: Advanced Bio Tech Products of 3 months. The course of the study was of 3 months (Ltd), * Chlosite®: Ghimas,Italy duration. The significance of the differences in plaque index, bleeding score, probing pocket depth and relati- ve attachment level for both the groups at different time Mean plaque score of both group I (Periodontal Plus intervals was assessed using paired t-test, while the in- AB®) and group II (Chlosite®) score at baseline (day ter-comparison of both the groups was carried out using 0) and at the end of 1 month and 3 months was highly unpaired t-test.
significant (p <0.001). On comparison of reduction in mean plaque score of group I (Periodontal Plus AB®) Clinical Parameters
and group II (Chlosite®) at different time intervals it was 1. Plaque Index (Quigley - Hein Plaque Index). found that reduction in plaque score after 1 month and 2. Probing pocket depth (using Williams's calibrated 3 months from baseline (day 0) was non-significant (p> periodontal probe) 3. Bleeding Index (PBI modified by Muhlemann HR) Mean papillary bleeding score of group I (Periodontal 4. Relative Attachment Level (Measurement using Plus AB®) and group II (Chlosite®) at day 0 and at the customized acrylic stent) end of 1 month and 3 months was highly significant (p< 0.001).On comparison , reduction in mean papillary bleeding score between the two groups was significant Tetracycline Fibers (Periodontal Plus AB®) #: Resorba- (p< 0.05).(Table 2) ble collagen fibers 25mg, impregnated with tetracycline Mean probing pocket depth of group I (Periodontal Plus hydrochloride containing approximately 1.7 ± 0.25mg AB®) and group II (Chlosite®) at day 0 and at the end of 3 months was highly significant (p <0.001). On compa- Chlorhexidine gel (Chlosite®)*: Xanthan based 1.5% rison, reduction in mean probing pocket depth of group chlorhexidine gel containing 0.5% fast releasing chlor- I (Periodontal Plus AB®) and group II (Chlosite®) after hexidine digluconate and 1% in form of slow releasing 3 months from baseline was significant (p< 0.05).(Table After 1 month from baseline After 3 months from baseline # t-value calculated using unpaired t-test and p value used to determine the statistical significance
Table 1. Comparison of reduction in mean plaque score of group I (periodontal plus ab®) and group II (Chlosite®) at 1 month and 3 months
from baseline (day 0)

J Clin Exp Dent. 2011;3(5):e424-9. Non surgical management of chronic periodontitis.
After 1 month from baseline After 3 months from baseline # t-value calculated using unpaired t-test and p value used to determine the statistical significance
Table 2. Comparison of reduction in mean papillary bleeding score of group I (Periodontal Plus AB®) and group II (Chlosite®) at 1 month and 3
months from baseline (day 0)

3months from baseline # t-value calculated using unpaired t-test and p value used to determine the statistical significance
Table 3. Comparison of reduction in mean probing pocket depth (mm) of group I (Periodontal Plus AB®)
and group II (Chlosite®) after 3 months from baseline (day 0).

reach the site of action in adequate concentrations and Mean relative attachment level of group I (Periodontal the inability to localize and sustain at disease active sites Plus AB®) and group II (Chlosite®) at day 0 and at the (17) . Recently, advances in local delivery technology end of 3 months was highly significant (p< 0.001). On have resulted in control release of drugs that are suc- comparison of relative attachment level gain of group I cessful in maintaining effective drug concentration at a (Periodontal Plus AB®) and group II (Chlosite®) after 3 lower dosage in the periodontal pocket. months was significant (p< 0.05) (Table 4).
It was observed in the present study, in both group I (tetracycline fibers) and group II (chlorhexidine gel), a reduction in mean plaque score that was statistically Scaling and root planing in conjunction with proper highly significant at both time intervals. Similar obser- plaque control results in alteration of the subgingi- vations were made by Jeong et al (18), Friesen et al (19), val environment that is sufficient, in most instances to Oosterwaal et al (20), Vinholis et al (12). This reduc- improve periodontal health and arrest further loss of tion in supragingival plaque score could be attributed to attachment(6). Nevertheless, scaling and root planing chemical control of subgingival plaque by tetracycline alone may not predictably lead to complete elimination fibers which could also have an inhibitory effect on su- of the disease (6). Poor access to the bottom of deep poc- pragingival plaque (21). Moreover, good oral hygiene kets and anatomical complexities may occasionally limit practiced by patients during the entire study period could the efficacy of root planing (3). Moreover, some bacte- have also increased the reduction in plaque. However ria have been shown to invade deep periodontal tissues, on comparison of mean plaque scores between group making mechanical therapy alone sometimes ineffective I and group II, statistically non-significant differences (16) and repopulation of scaled teeth from bacterial re- were recorded and the findings are in accordance with servoirs in dentinal tubules may also be responsible for the study conducted by Unsal et al (15) who evaluated recurrence of the disease (3). the effects of subgingivally placed 2% chlorhexidine gel Various antimicrobial agents have been administe- and 10% tetracycline paste in periodontal pockets along red systemically as well as locally/topically by means with scaling and root planing. of mouth rinses or irrigation solutions as an adjunct to Bleeding on probing is an objective sign of inflamma- scaling and root planing (14). However systemic admi- tion. Research suggests that bleeding on probing often nistration of antibiotics have been associated with side is the first sign of gingival inflammation. Reduction in effects, while effectiveness of local delivery of antimi- mean bleeding score in both groups was highly signifi- crobial agents in form of mouth rinses and subgingival cant at both time intervals and the results are in accor- irrigation has been limited due to inability of the drug to dance with studies conducted by Minabe et al (22). In 3months from baseline # t-value calculated using unpaired t-test and p value used to determine the statistical significance
Table 4. Comparison of gain in mean Relative attachment level (mm) of group I (Periodontal Plus AB®)
and group II (Chlosite®) after 3 months from baseline (day 0)

J Clin Exp Dent. 2011;3(5):e424-9. Non surgical management of chronic periodontitis.
the present study reduction in bleeding is due to resolu- riodontal pocket depth in group II (Chlosite®) at the end tion of gingival inflammation after scaling and root pla- of 3 months from baseline (day 0), however reduction ning and well known antimicrobial effect of tetracycline was lower when compared to group I (Periodontal Plus (15, 23).Moreover, average gingival fluid concentration AB®) at the end of 3 months. This could be attributed to of 1500 µg/ml tetracycline has been observed during the fact that chlorhexidine offers a low subgingival subs- the first 10 days treatment period with Periodontal Plus tantivity and there is poor adsorption of the drug in the AB®. Tetracycline is released in almost linear fashion for subgingival environment when compared to tetracycline 7-10 days. Similar findings were noted by Aimetti et al (23). In a systematic review on the effects of subgingival (6) and Heijl et al (25). On comparison of bleeding sco- chlorhexidine gel adminstration in treatment of chronic res between the two groups, reduction in mean papillary periodontitis, it was concluded that the limited data cu- bleeding score was significant at both 1 and 3 months rrently available on the effects of subgingival chlorhexi- (p< 0.05). There was more reduction in the tetracycline dine gel application do not justify its use in the treatment group, which can be attributed to the fact that tetracycli- of chronic periodontitis (28) .However in a more recent ne offers better substantivity (23) and good binding and/ randomized multicenter trial, xanthan based chlorhexi- or penetration into the root surfaces (24) when compared dine gel promoted greater pocket reductions and clinical to chlorhexidine and thereby maintaining antimicrobial attachment gains with better microbiologic and bioche- effect for a longer time period.
mical outcomes compared with scaling and root planing Periodontal probing is one of the most widely used diag- alone (29). Moreover addition of chlorhexidine to xan- nostic tools for clinical assessment of connective tissue than gum seem to improve the bioadhesive properties of destruction and periodontal pocket depth in periodontal this material and the cationic charges of chlorhexidine disease. In both groups the reduction in mean probing can interact with the anionic charges of the xanthan gum pocket depth was highly significant and a similar result polymer, enhancing its gel structure and substantivity was recorded by Goodson (11), Heijl et al (25), Rad- (30).This in concordance with our findings as xanthan var et al (3), Friesen et al (19) and Stabholz et al (23), based chlorhexidine gel was effective in reducing pocket Jeffcoat et al (14) and Vinholis et al (12). However, on probing depth and there was gain of attachment.
comparison, mean probing pocket depth reduction bet- ween group I and II was significant (p <0.05) at the end of 3 months, with better results in group I. Reduction in Both tetracycline fibers and chlorhexidine gel are an probing pocket depth in both the groups (Group I and II) effective means of non-surgical treatment modality for is due to resolution of gingival inflammation after sca- the management of chronic periodontitis. The adjuncti- ling and root planing and to well known antimicrobial ve use of both the agents along with scaling and root effects of both locally delivered drugs. Unsal et al (15) planing resulted in a significant improvement in all the and Stabholz et al (23). clinical parameters. Although tetracycline fibers resulted Pocket depth might change from time to time even in un- in better improvement in probing pocket depth reduction treated periodontal disease because of changes in gingi- and relative attachment level gain than chlorhexidine val margin, while changes in the level of attachment can gel, more studies with a large sample size are required to be caused only by gain or loss of attachment and thus further assess the comparative clinical efficacy of both provide a better indication of the degree of periodontal the local drug delivery agents.
destruction. There was highly significant gain (p <0.001) in both group I (tetracycline fibers) group II (chlorhexi- References
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A mixture of amino acids and other small molecules present in the serum suppresses the growth of murine and human tumors in vivo

International Journal of Cancer A mixture of amino acids and other small molecules presentin the serum suppresses the growth of murine and humantumors in vivo ´ kos Schulcz2 and Tamas Cz€omp€oly1 1 Immunal Ltd., Cancer Research and Product Development Laboratory, H-7630 Pecs, Finn u. 1/1., Hungary2 Department of Experimental Pharmacology, National Institute of Oncology, H-1122 Budapest, Rath Gy€orgy u. 7-9., Hungary

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