A double-blind placebo-controlled trial of azithromycin as an adjunct to non-surgical treatment of periodontitis in adults: clinical results.

BACKGROUND/AIMS: The aim of the study was to investigate the clinical and microbiological effects of azithromycin as an adjunct to the non-surgical treatment of periodontitis in adults. Azithromycin is an antibiotic which is taken up by phagocytes and is released over long periods in inflamed tissue but requires a total of only three doses of 500 mg to produce its therapeutic effect. METHOD: 46 patients were treated in a double-blind placebo-controlled study with assessments at weeks 0, 1, 2, 3, 6, 10 and 22. Throughout the trial measurements were made of plaque, gingival bleeding, calculus, probing pocket depths and bleeding on probing. Microbiological sampling was carried out from a selected pocket >or=6 mm at each visit. The regime employed consisted of OHI, scaling and root planing at weeks 0, 1 and 2 with reinforcement of OHI and minimal scaling at weeks 6, 10 and 22. Patients were randomly assigned to receive either azithromycin, (A), or placebo capsules, (C), 500 mg, 1x daily for 3 days at week 2. 44 patients completed the study. Mean pocket depths were analysed using analysis of covariance in 3 groups with initial pocket depth values of 1-3 mm, 4-5 mm and >or=6 mm. RESULTS: The results of the microbiology have been reported in a separate paper. The clinical data showed that by week 22 a lower % of pockets initially >5 mm deep remained above that level in the 23 patients taking azithromycin (A), than the 21 taking the placebo (C), (A, 5.6%; C, 23.3%). Also at week 22, for pockets initially 4 mm or more, the test group had fewer pockets >3 mm deep (A, 26.1%; C, 44.3%), fewer failing to improve in probing depth (A, 6.6%; C, 21.6%) and fewer continuing to bleed on probing (A, 46.9%; C, 55.6%) when compared with the control group. Pocket depths initially 4-5 mm or 6-9 mm analysed by analysis of covariance showed lower mean pocket depths in the patients on azithromycin, at weeks 6, 10 and 22, (pockets initially 4-5 mm, p<0.001 on all occasions, pockets initially 6-9 mm, p<0.001, week 6; p< 0.003, week 10; p<0.001, week 22). CONCLUSIONS: Azithromycin may be a useful adjunct in the treatment of adult periodontitis, particularly where deep pockets are present.

The effect of a sodium lauryl sulfate-free dentifrice on patients with recurrent oral ulceration.

OBJECTIVE: Sodium lauryl sulphate (SLS) is the most commonly used detergent in dentifrices. Recent reports have suggested that it may exacerbate conditions with compromised epithelial integrity. The aim of this study was to compare the effect of an SLS-free dentifrice and an SLS-containing dentifrice on recurrent oral ulceration (ROU). DESIGN: A double-blind crossover clinical trial was carried out during which subjects used an SLS dentifrice for 8 weeks and an SLS-free dentifrice for 8 weeks. Each phase was preceded by a 2-week washout period. SETTING: A UK dental teaching hospital. SUBJECTS AND METHODS: Forty-seven subjects completed the trial. They were all in the age range 10-62 years, had regularly recurrent oral ulceration reporting at least one to two ulcers per month and had normal levels of vitamin B12, ferritin and folate. MAIN OUTCOME MEASURES: The trial phases were compared for the following ulcer parameters--number of ulcer days, total pain scores, number of ulcer episodes, and number of ulcers. Additional parameters compared were the number of ulcers per episode, ulcer duration, total pain per episode and ulcer size. RESULTS: None of the ulcer parameters measured was significantly affected by the use of the SLS-free dentifrice as compared with the SLS dentifrice. CONCLUSION: SLS-free dentifrice had no significant effect on ulcer pattern in the ROU study group.

Oral complications of cancer therapies: prevention and management.

There is no doubt that, when the oncology team includes a dentist, the risks of development of serious complications such as osteoradionecrosis are significantly reduced for the cancer patient [15,157,158]. Ideally, all patients should be rendered dentally fit before the commencement of cancer therapy. Those receiving radiotherapy should then be seen weekly by the dentist during the course of radiotherapy and approximately every 1-2 weeks during the intensive phases of treatment, if receiving chemotherapy or surgery. All patients should be carefully followed up after cancer therapy in order to minimize orofacial complications and be in a position to intervene at an early stage, when therapy is likely to be easier and more rapidly effective.

Marginal ditching and staining as a predictor of secondary caries around amalgam restorations: a clinical and microbiological study.

Caries at the margins of restorations is difficult to diagnose. In particular, the relevance of both marginal ditching and staining around amalgam restorations is unclear. This clinical study questions the relevance of marginal ditching and color change to the level of infection of the dentin beneath the margins of amalgam restorations. Clinically visible sites (330) on the tooth/restoration margin were selected on 175 teeth. The enamel adjacent to each site was noted as stained (a grey discoloration) or stain-free. One hundred and seventy-eight sites were clinically intact, 83 sites had narrow ditches (< 0.4 mm), and at 49 sites, wide ditches were present (> 0.4 mm). Twenty sites with frankly carious lesions were also included. Plaque was sampled at the tooth-restoration margin, and the dentin was sampled at the enamel-dentin junction below each site. Samples were vortexed, diluted, and cultured for total anaerobic counts, mutans streptococci, lactobacilli, and yeasts. Plaque samples showed that margins with wide ditches (> 0.4 mm) harbored significantly more bacteria, mutans streptococci, and lactobacilli than did clinically intact margins and margins with narrow ditches. There were no significant differences in the degree of infection of the dentin beneath clinically intact restorations and those with narrow ditches, but samples associated with wide ditches and carious lesions yielded significantly more bacteria, mutans streptococci, and lactobacilli. The color of the enamel adjacent to the sample site was irrelevant to the level of infection of the dentin beneath the filling margin, provided a frankly carious lesion was not present.(ABSTRACT TRUNCATED AT 250 WORDS)

How should we use dietary fluoride supplements?

Since January 1993 general dental practitioners have been able to prescribe dietary fluoride supplements in the form of drops or tablets for their child patients within the conditions of service of the General Dental Service. Many GDPs may already have taken advantage of this to the benefit of their patients. However, in recent years more evidence has become available about the impact of such fluoride supplements on the teeth.

Update on fissure sealants.

The pit and fissure sealants that are commercially available today are designed to prevent plaque, bacteria and carbohydrates from entering the fissures and causing caries. This article will concentrate on contemporary diagnostic problems and indications for fissure sealing. Brief mention will be made of innovations in materials and techniques.

Diagnosis of secondary caries: a laboratory study.

Secondary caries is difficult to diagnose accurately. The purpose of this laboratory study was to investigate various non-invasive clinical and radiographic criteria which might predict the presence of carious dentine beneath the margin of the filling. A total of 331 sites, each 3 mm in length on the tooth restoration margin, were selected on 112 extracted and filled teeth. Thirty of these sites showed obvious carious cavities. Ditching was apparent in a further 70 sites, while 231 sites were clinically intact. Staining of the margin of the filling was recorded and radiographs were taken of posterior teeth. Restorations were then removed and the enamel-dentine junction (EDJ) immediately below the sites was examined for its consistency (hard/soft) and colour (stained/stain-free). Results showed that staining around a filling is not a reliable predictor of softening or discolouration of the dentine beneath. A clinical carious cavity and radiographic evidence of demineralisation indicate soft and discoloured dentine and should trigger operative intervention, while ditching alone should not.

The use of a caries detector dye during cavity preparation: a microbiological assessment.

During cavity preparation conventional tactile and optical criteria are used to assess the caries status of the enamel-dentine junction, cavity preparation being considered complete when this area is hard to a sharp probe and stain free. In the present study 201 cavities were prepared under rubber dam. When caries removal was considered complete using the conventional tactile and optical criteria, a caries detector dye (1% acid red in propylene glycol), which is claimed to stain 'infected' tissue red, was applied. Fifty-two per cent of cavities showed caries dye stain in some part of the enamel-dentine junction. Subsequent microbiological sampling of dye-stained and dye-unstained sites resulted in the recovery of low numbers of bacteria and revealed no difference in the level of infection of the two sites. It is concluded that the conventional tactile and optical criteria are satisfactory assessments of the caries status of tissue during cavity preparation and that subsequent use of a caries detector dye on hard and stain-free dentine will result in unnecessary tissue removal.

Microbiological validation of assessments of caries activity during cavity preparation.

The operative management of primary and secondary caries assumes that all discoloured tissue at the enamel-dentine junction (EDJ) represents active disease and this is removed to arrest the carious process. This study aims to establish clinical criteria to differentiate between active and arrested caries at the EDJ using microbiological assessment of dentine samples to verify its clinical status. Radiographs were available for posterior teeth. Cavities (n = 205) were prepared under rubber dam. After gaining access, areas of the EDJ were chosen and assessments made of consistency (soft, medium, hard), colour (dark brown, mid-brown, pale) and moisture content (wet, dry). Dentine was removed by using a No. 3 round burr and placed in 1 ml of bacteriological culture broth. This sampling procedure was repeated at the same site once during cavity preparation and again when the cavity was judged as fully prepared. Samples were vortexed, diluted and cultured to give viable counts of the total anaerobic microflora, mutans streptococci and lactobacilli; viable counts were expressed as log10 (CFU per sample +1). Results showed no significant differences between the microflora of primary and secondary caries. The number of bacteria recovered diminished significantly as cavities were completed. Initial samples from soft and wet lesions harboured significantly more bacteria, lactobacilli and mutans streptococci than samples from medium, hard or dry lesions. Lesions visible on radiographs harboured more bacteria, including lactobacilli and mutans streptococci, while dentine colour was not discriminatory.(ABSTRACT TRUNCATED AT 250 WORDS)

The effect of a mouthrinse containing chlorhexidine and fluoride on plaque and gingival bleeding.

The aim of this study was to test the effect of a rinse with 0.05% sodium fluoride and 0.05% chlorhexidine on plaque and gingival inflammation compared with a placebo without these agents. In a double-blind study, 47 adults with > 20 teeth and a CPITN score > 1 but < 4 were randomised into test and control groups. After baseline assessments for plaque, bleeding and stain, teeth were professionally cleaned. Subjects were asked to rinse for 30 s with 10 ml of the respective test or placebo rinse after normal oral hygiene for 8 weeks. 39 subjects completed the study. There was no significant difference in the 2 groups at baseline with respect to either plaque or bleeding scores. After scaling and 8 weeks use of the test rinse, there were significant reductions (p < 0.001) in both plaque and bleeding. The control group showed no significant reduction in plaque scores after 8 weeks, but a significant (p < 0.05) reduction in bleeding. However, this reduction was significantly greater (p < 0.001) in the test group than in the control. The test group had a significantly greater (p < 0.05) stain score than the control at baseline. After scaling and rinsing for 8 weeks, stain scores were lower for both groups compared to baseline but reached significance (p < 0.05) only for the control group. It is concluded that, as an adjunct to normal oral hygiene, the chlorhexidine/fluoride rinse had a significant inhibitory effect on plaque and bleeding but its effect on staining is uncertain.

The effect of using a pre-brushing mouthwash (Plax) on oral hygiene in man.

The aim of this study was to investigate whether the use of a pre-brushing mouthwash (Plax) improved subjects' oral hygiene over a 2-week period. In a double-blind placebo controlled cross-over study, 33 adult subjects (mean age 35.3 years) used either Plax or a placebo mouthwash for 30 s prior to toothbrushing during a 2-week period. After a washout period of 4 weeks, the subjects used the other mouthwash in the same way. The modified plaque index of Quigley and Hein (QHI) was recorded for 16 teeth (16, 14, 13, 11, 21, 23, 24, 26, 36, 34, 33, 31, 41, 43, 44, 46) at each visit. The bleeding index (BI) was recorded at the beginning and end of the study. Results were analysed using a paired one-tailed t-test. Neither plax nor placebo mouthwashes reduced plaque scores significantly (p > 0.05) below baseline. There was no statistically significant difference between the mean BI at the beginning of the trial (0.42) and at the end (0.44). These results suggest that the routine use of Plax is not a useful adjunct to toothbrushing.

Management of oral complications following radiotherapy.

Radiotherapy for the treatment of neoplastic disease in the head and neck region results in a number of oral changes liable to cause pain and discomfort during therapy. In the longer term, it increases the patient's susceptibility to caries and periodontal disease. The aim of this paper is to outline these changes and to suggest a regime for the dental management of these patients before, during and after radiotherapy. The role of the dentist in support, advice and treatment is vital.

Prevention of dental diseases following radiotherapy and chemotherapy.

The general dental practitioner should be aware of the oral changes that take place during chemotherapy and radiotherapy for neoplasms in the head and neck regions. Some of the changes make patients more vulnerable to dental diseases and complications if teeth need to be extracted. Ideally, patients should be made dentally fit before treatment, in order to avoid the risk of extractions later. In the long term, periodontal diseases and caries can be controlled with adequate monitoring and with appropriate use of chlorhexidine and fluoride.

Caries incidence, mutans streptococci and lactobacilli in irradiated patients during a 12-month preventive programme using chlorhexidine and fluoride.

Radiotherapy (RT) near salivary glands results in changes in the oral flora in favour of cariogenic organisms and an increased susceptibility to caries. The aim of this study was to assess the effect of a 12-month preventive programme on caries incidence and on the levels of mutans streptococci (ms) and lactobacilli in tongue loop samples taken from patients before, during and after RT. The regime consisted of 2 x daily rinsing with 10 ml 0.2% chlorhexidine, diluted 1:1 with water, for 1 week before RT, during RT and for 4 weeks after RT. This was then substituted with a 0.05% NaF rinse daily. A saliva substitute containing 2 ppm F was used as required. Scaling was carried out before RT and dietary advice and oral hygiene instruction given. Appropriate radiographs were taken at baseline and after 6 and 12 months. Tongue loop samples for microbiology were taken in the middle and end of RT and subsequently at 6, 8, 12, 24, 40 and 52 weeks. Whenever levels of ms exceeded 2 x 10(5) cfu/ml sample, 1% chlorhexidine gel in custom-made applicator trays was applied by the subject for 5 min daily for 14 days. In 25 subjects completing the programme, there was a total of 3 new caries lesions after 12 months. Thirteen pre-existing enamel lesions were arrested. There were significant reductions (p < 0.005) in ms levels from baseline values during RT and 4 weeks after RT. There were no significant increases in ms levels throughout the study.(ABSTRACT TRUNCATED AT 250 WORDS)

Staining of residual caries under freshly-packed amalgam restorations exposed to tea/chlorhexidine in vitro.

Discoloration around restorations may lead practitioners to suspect recurrent caries. Dentists, using conventional optical and tactile criteria, often fail to render the enamel-dentine junction completely caries-free during cavity preparation. The aim of the present laboratory study was to test the hypothesis that such residual caries could take up stain from tea and hence affect clinical judgement on the presence of recurrent disease. Cavities were prepared in freshly extracted carious teeth and restored with amalgam. Specimens were then temperature cycled in tea and chlorhexidine or in tea alone to encourage leakage. Subsequent removal of restorations showed staining of parts of the enamel-dentine junctions and histological examination showed these stained areas to correspond to areas of demineralization. Similarly prepared caries-free teeth showed no such staining. Thus residual caries in teeth with leaking restorations can, in the laboratory, take up stain. If this were to happen in vivo, stained residual caries could subsequently be misdiagnosed as recurrent caries.

Depth of occlusal caries assessed clinically, by conventional film radiographs, and by digitized, processed radiographs.

Occlusal caries depth was assessed in 47 extracted premolars and permanent molars by 4 observers on a rank scale by eye inspection, by film radiographs, and by 2 of the observers also by digitized radiographs after filtering and contrast enhancement of the image. Quantitative estimates of caries depth were obtained from the digitized radiographs. Accuracy of scorings was determined with the histologic section as validating criterion. Occlusal caries was present in a spectrum from incipient fissure decalcification to large cavity formation. Clinical as well as radiographic scorings most frequently under-estimated lesion depth. Accuracy of radiographic assessments increased substantially by digital processing of the radiographic image. Quantitative measures of caries depth on digitized radiographs were strongly correlated to the histologic measures (r = 0.91). Interobserver agreement was fair to moderate according to kappa coefficients for the clinical and the radiographic scorings. The agreement was highest for the scorings of the digitally enhanced images. The study suggests that digital processing of radiographic images constitutes a diagnostic aid that may give a more accurate estimate of occlusal caries depth.

The use of a caries detector dye in cavity preparation.

The aim of this study was to compare the conventional visual and tactile method of detecting carious dentine during cavity preparation using a mirror, probe and excavator with a visual method enhanced by a dye. The dye, 1% acid red in propylene glycol, was used on 100 cavities prepared by dental students and passed as clinically satisfactory by their teachers. Results showed dye stain at the enamel-dentine junction in 57 cavities (57%) which had been assessed as caries-free in this area using conventional visual and tactile means. Subsequent laboratory work on extracted carious teeth confirmed histologically that the dye stains demineralised dentine. If clinicians consider it important to render the enamel-dentine junction caries-free, it might be prudent to use the dye as an aid to diagnosis in this area.

Agentes tópicos y sistémicos antimicrobianos en el tratamiento de la gingivitis y de la periodontitis crónica

Los métodos mecánicos deben preferirse generalmente al empleo de cualquier agente químico para el control rutinario de la placa en el tratamiento de la gingivitis. Sin embargo, el uso supervisado de clorhexidina a corto plazo está recomendado en las siguientes circunstancias: 1.Después de la cirugía oral: enjuague durante 1 minuto con 10ml de una solución al 0.2 por ciento, 2 veces al día durante 1 á 2 semanas. 2.Fijación intermaxilar: irrigación una vez al día con 400ml de una solución al 0.02 por ciento. 3.Pacientes debilitados: enjuague durante 1 minuto, dos veces al día con 10ml de una solución al 0,2 por ciento o irrigación una vez al día con 400ml de una solución al 0.02 por ciento. 4.Individuos incapacitados físicamente o mentalmente: uso intermitente de la clorhexidina en forma de enjuague, gel o spray. Periodontitis: Todos los pacientes adultos deben ser tratados convencionalmente mediante el control de la placa y raspaje y alisado radicular completos y, en algunas circunstancias, cirugía menor. Los pacientes que no respondan a este tratamiento a pesar del control meticuloso de la placa deben ser remitidos a un especialista que puede decidir administrar un tratamiento corto a base de tetraciclina o metronidazol. Es imperativo que los pacientes sean regularmente monitorizados porque las recidivas serán inevitables si no se mantiene el control de la placa. Periodontitis Juvenil: El tratamiento convencional incluyendo control de la placa, raspaje y alisado radicular debe incluir una pauta de digamos 250mgr. de tetraciclinas 4 veces al día durante 3 semanas. La monitorización clínica resulta imperativa y son deseables las determinaciones microbiológicas. Metronidazol: Principales efectos secundarios: trastornos gastrointestinales, náuseas, vómitos, sensación de sabor metálico, cefaleas y ocasionalmente vértigos. (Se ha referido mutagenicidad en bacterias y carcinogenicidad en ratas). Contraindicaciones: CNS activa, discracia sanguínea. Reacción similar a la del disulfiram con alcohol. Pacientes en tratamiento con warfarina y antihipertensivos. Embarazo. Tetraciclina y Minociclina: Principales efectos secundarios: Náuseas, vómitos, diarrea, rash cutáneo y fotosensibilidad. Sobreinfección con cándida albicans. Hepatoxicidad cuando se utiliza durante el embarazo, shock y sepsis. Decoloración dental permanente si se administra durante la segunda mitad del embarazo y vértigos. Contraindicaciones: Embarazo y niños hasta los 7 años de edad