Systematic review and meta-analysis on the adjunctive use of host immune modulators in non-surgical periodontal treatment in healthy and systemically compromised patients

Abstract

Considering the central role of inflammation in the pathogenesis of periodontitis, the combination of NSPT with different agents that can modulate the host immune-inflammatory response has been proposed to enhance the outcomes of NSPT. The aim of this paper is to systematically review the literature on the efficacy of systemic host modulators (HMs) as adjuncts to non-surgical periodontal therapy (NSPT) in improving pocket depth (PD) reduction and clinical attachment level (CAL) gain in healthy and systemically compromised patients. RCTs with ≥ 3 months follow-up were independently searched by two reviewers. Meta-analysis was performed when ≥ 3 studies on the same HM were identified. The quality of the evidence was rated according to the GRADE approach to rate the certainty of evidence. 38 articles were included in the qualitative assessment and 27 of them were included in the meta-analysis. There is low/very low evidence that the adjunctive use of sub-antimicrobial dose of doxycicline, melatonin and the combination of omega-3 and low dose aspirin (in type 2 diabetic patients) to NSPT would improve PD and/or CAL. Conflicting evidence is available on the efficacy of probiotics. Future studies controlling for confounding factors, using composite outcomes to define the endpoint of therapy and considering not only the patient- but also as the site-specific effect of systemic HMs are warranted. The dosage, posology and long-term effect of HMs still need to be clarified, also in association to the presence of systemic conditions potentially affecting the response to HMs administration.

Causes of Emergency Bleeding after Nonsurgical Periodontal Therapy in Adult Periodontitis Patients: A Retrospective Analysis

“…NSPT has been proved to improve the level of clinical attachment and effectively reduce the probing pocket depth [ 22 , 23 ]. Therapy includes oral hygiene instruction, subgingival scaling, and root planing [ 5 ]. Gingival bleeding is the most common complication after supra- and subgingival curettage and the most common symptom in periodontal emergency departments [ 24 ].…”

“…The goal of the periodontitis therapy is to address gingival inflammation and restore periodontal health. Periodontal therapy always begins with nonsurgical periodontal therapy (NSPT) [ 5 ]. NSPT is engaged to preserve, improve, and maintain natural dentition [ 6 ], including by controlling (reducing/eliminating) the subgingival biofilm and calculus through manual subgingival instrumentation and follow-up in all periodontitis patients, irrespective of the disease stage, for all teeth with loss of periodontal support and/or periodontal pocket formation [ 7 ].…”

The efficacy of adjunctive periodontal therapies during supportive periodontal care in patients with residual pockets. A systematic review and meta‐analysis

“…Moreover, the majority of included studies aggregated patient‐level data providing mean full‐mouth clinical periodontal measurements. Although this allows to assess an overall effect of the different adjunctive therapies on the periodontal condition of the patient, it should be recognized that periodontitis is most often a site‐specific disease, and by aggregating patient‐level evaluations there is the risk of losing important information and diluting the real effect that these therapies might have had 14 . It is, therefore, recommended that future studies should perform multilevel analyses to assess not only patient‐level but also site‐level responses to adjunctive therapies.…”

“…While it appears that most probably adjunctive therapies should not be used routinely as an adjunct to subgingival instrumentation, some recent studies have suggested that they might be particularly beneficial in specific cases, which might include sites that did not adequately respond to the initial nonsurgical therapy, or they might provide additional benefits in specific categories of patients, such as patients affected by systemic diseases (e.g. diabetes mellitus) with an inflammatory pathogenesis 14,15 . For instance, although systemic probiotics did not show to significantly improve the outcomes of subgingival instrumentation in previously untreated periodontitis patients, 15 two recent RCTs suggested a significant improvement in pocket reduction when used as an adjunctive treatment in patients with residual pockets 16,17 …”

“…diabetes mellitus) with an inflammatory pathogenesis. 14,15 For instance, although systemic probiotics did not show to significantly improve the outcomes of subgingival instrumentation in previously untreated periodontitis patients, 15 two recent RCTs suggested a significant improvement in pocket reduction when used as an adjunctive treatment in patients with residual pockets. 16,17 This systematic review aimed to provide evidence-based indications for clinicians when considering the use of adjunctive therapies other than antimicrobials during step 4 of therapy in the presence of residual/relapsing pockets.…”