METODE NON-CHIRURGICALE ÎN TRATAMENTUL PARODONTITEI

CRONICE
EFICACITATEA APLICĂRII FIBRELOR DE TETRACICLINĂ DUPĂ
REALIZAREA TRATAMENTULUI MECANIC

INTRODUCTION
Periodontal diseases represent a group of localized microbial induced infections involving
the gingival and supporting tissues of the teeth, resulting in progressive loss of attachment and
formation of periodontal pockets.
The control of prevalence and progression of periodontal disease requires a reduction of
sub-gingival microbial plaque mass or at least a suppression of periodontopathic bacteria.1
Removal or inhibition of subgingival plaque thus plays an important role in the
maintenance of oral health.[3] The main goal of periodontal therapy is not only to stop periodontal
destruction but also to prevent the recurrence of disease and regeneration of lost tissues.[4]
Periodontal diseases are routinely treated by mechanical procedures which include
meticulous scaling and root planing in conjunction with patient’s proper plaque control.
Periodontal debridement may not eradicate these species like A. actinomycetemcomitans and
P.gingivalis due to their invasive potential into gingival epithelial cells and subepithelial
connective tissue, and their high affinity for crevicular epithelium and dentinal tubule.
Consequently, this has led to adjunctive use of antimicrobials, assuming that chemical aids would
compensate for technical shortcomings and prevent early microbial re-colonization to ultimately
ensure the best chance for clinical improvements.3
There is growing interest in localised antimicrobial therapy because of the site-specific
nature of periodontal infections, greater subgingival concentrations of antimicrobial agent, and
reduced side-effects compared to systemic antibiotics.3 The periodic use of local drug delivery
helps to minimise bleeding and stabilise attachment levels, thereby reducing probing pocket depth.
However, systemic drug therapy is limited by adverse reactions such as toxicity, acquired
bacterial resistance, and drug interactions. Patient compliance is also a recognized problem. In
contrast, local administration of the drug allows the therapeutic agent to be delivered at the
diseased periodontal site with increased therapeutic effect and minimal side effects. However,
topically applied drugs do not have sufficient time to exert their bacteriostatic or bactericidal effect
on targeted microorganisms residing in the subgingival area.
The antimicrobial agents used as local drug delivery agents include tetracycline, ofloxacin,
clindamycin, chlorhexidine, etc. Tetracycline as well its derivatives doxycycline and minocycline
are the most commonly used antimicrobial agents in the treatment of periodontal infections.
Tetracycline also binds to the root surfaces and can be released in active form over extended
periods of time. The sub-lethal concentration of tetracycline reduces adherence and co-aggregation
properties of a number of disease associated bacteria including P. gingivalis and P. intermedia.8-
10 The other properties of tetracyclines are inhibition of bone resorption, anti-inflammatory
actions, and to promote the attachment of fibroblasts and connective tissue to root surfaces in
periodontal therapy.
MATERIALS AND METHODS

Sharma, et al. used 35 patients who were diagnosed with generalized chronic moderate
periodontitis, with two contra-lateral sites with ≥ 5 mm periodontal pocket with active lesion, and
radiographic evidence of bone loss, clinical attachment loss ≥ 3 – 5 mm at the base line, patients
who had not undergone any surgical or nonsurgical periodontal therapy in the past 6 months, and
patient who are not willing for surgical therapy, Patients able to follow verbal or written oral
hygiene instructions.
Test group - included 35 sites that were selected for the placement of Periodontal Plus
AB; Tetracycline fibers (local drug delivery) after scaling and root planing. Control group -
included 35 sites that were treated with scaling and root planing alone (without local drug
delivery).
Clinical parameters taken were the PI, GI, SBI, probing depth (PD), and clinical
attachment level (CAL). Anaerobic culture was done to compare the total colony forming unit
before and after the treatment were recorded at 0, 30 and 90 days.
The present study was designated to access the clinical efficiency of tetracycline-
impregnated bio-degradable collagen fibers, by evaluating the changes in plaque index and
gingival index, sulcular bleeding index, changes in probing pocket depth and clinical attachment
level. Also the changes in total anaerobic colony count was evaluated over a period of 3 months.
Dang, et al used a total of twenty patients comprising of both sexes in the age group of
35‑60 years with chronic periodontitis were selected. Split‑mouth design was used, and three teeth
from each patient with periodontal pocket measuring > 5 mm were selected which were treated
with different treatment modality.
They were randomly divided into site A (SRP), site B (tetracycline fibers only), and site C
(combination therapy).
Clinical parameters of plaque index (PI), gingival index (GI), pocket probing depth, and
clinical attachment level (CAL) were recorded at 0, 30, and 45 days. The data obtained was
compiled and put to statistical analysis.

RESULTS
Sharma et al. obtained a statistically significant reduction in plaque score and gingival index score
from baseline to 3 months for both treatment group (P<0.001) was observed. However better result
in the reduction in plaque score and gingival index score was observed in the test group.
On comparison between the two groups, the probing depth reduction at all time points was
greater in the scaling plus tetracycline fiber group than the scaling and root planning alone group,
which was statistically significant.
On comparison between the two group, the gain in CAL at all time points was significantly
greater in the scaling plus tetracycline fiber group than the scaling and root planing alone group
More statistically significant reduction observed in the test group at 21 days, compared
with the control for total anaerobic colony count, proves the efficacy of the drug tetracycline fiber
as an antimicrobial agent.

Dang el. obtained the following results:

In Group A, for all the parameters, a fall in mean value was observed with time. The mean
value for all the parameters was maximum on day 0 and minimum on day 45 [Table 6].
In Group B, for all the parameters, a fall in mean value was observed with time. The mean
value for all the parameters was maximum on day 0 and minimum on day 45 [Table 7].
 In Group C, a gradual decrease in the values of all clinical parameters from baseline to 45
days was observed [Table 8].

DISCUSSIONS
Sharma et al. concluded that a number of different nonsurgical and surgical therapies have
been successful in achieving the goal of current periodontal therapy - successful management of
the suspected bacterial pathogens. Mechanical therapy may however fail to eliminate the
pathogenic bacteria because of their location within gingival tissues or in other areas inaccessible
to periodontal instruments
Most widely used local drug delivery system reports in periodontal literature are
Tetracyclines.
In the present study, collagen-impregnated tetracycline fibers were found to be
advantageous among other drugs. Tetracyclines are superior to other antibiotics as they are the
only class of antibiotics which has the ability for retention to the tooth cementum and soft tissues.
Tetracycline is suitable to local delivery and as adjuncts to mechanical therapy in
management of periodontal disease
Decrease in bleeding on probing could be attributed to the fact that these local drug delivery
systems maintain adequate antimicrobial drug level over a sufficient period of time.
The study showed a highly statistical significant (P< 0.001) reduction in probing depth
from baseline to 3 months in both control and test group. On comparison between the two groups,
the probing depth reduction at all time points was greater in the scaling plus tetracycline fiber
group than the scaling and root planning alone group, which was statistically significant.
Local tetracycline therapy and SRP causes the arrest of disease progression by altering the
subgingival microbiota and to create a more healthy sub-gingival environment. In addition to the
antimicrobial effects, it is possible that tetracycline fiber may have effects on the local periodontal
environment. These effects may include chemical conditioning of the root surface.
Dang et al. observed that the reduction in plaque and GI was associated with proper home
care by patients and was reflected in respective decrease in PD and gain in loss of attachment.
Moreover, the greatest therapeutic benefits when using a combination of SRP and tetracycline
fiber. The principal objective of both tetracycline fiber therapy and scaling is to arrest disease
progression by allowing the subgingival microbiota and creating a healthier periodontal
environment it is interesting to note that subgingival debridement was not performed in the site
receiving only tetracycline fibers; yet benefits were seen that surpassed those of mechanical
therapy alone.

CONCLUSIONS
The studies demonstrated that the efficacy of mechanical treatment, as part of chronic
therapy periodontitis, is enhanced by the local application of medication on the affected site. Also,
the results were maintained by following the indications regarding a good oral hygiene. This was
obtained by correct brushing method – Bass method – associated with adjuvant methods –
mouthwash, oral irrigators, etc.
Using tetracycline impregnated collagen fibers have both therapeutic and biostimulator
effect: on one hand through the affinity of tetracycline for Calcium ions, on the other hand,
facilitating the aggregation of fibroblasts (cellular matrix and collagen synthetizing cells), allowing
tissue regeneration. Locally delivered tetracycline therapy has a specific purpose, to control
localized infection, whereas scaling is utilized to remove calculus and other deposits. Hence, a
combination of scaling and local drug delivery results in added benefits in the control of
periodontal disease.