Antibiotic therapy as an adjunct to scaling and root planing in smokers

cigarettes-78001_1280Introduction

It has long been established that smoking is a significant modifying factor in the progression of periodontal disease and eventual tooth loss (Dietrich et al. 2015; Zeng et al. 2014). The established treatment of periodontal disease is based on the elimination of pathogens through subgingival scaling and root planing (SRP), if periodontal disease remains following this initial ‘hygienic phase’ then treatment can be repeated with the addition of systemic antibiotics too good effect (Keestra et al. 2014; Rabelo et al. 2015). Thus, the aim of this study is to conduct a systematic review and meta-analysis to evaluate the effectiveness of systemic antibiotic therapy associated with periodontal treatment in smokers.

Methods

This review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement with the focused question; “Do adjunctive antimicrobials improve the clinical outcome of non-surgical therapy (scaling and root planing [SRP]) in the treatment of periodontitis in smokers?”

The following inclusion criteria were applied:  Randomized controlled clinical trials; studies published in English; studies with smoker patients (at least 10 cigarettes per day for at least five years) diagnosed with chronic periodontitis; patients without significant systemic diseases ; aged between 30 and 70 years; not receive periodontal treatment in the last six months; used systemic antibiotic therapy associated with periodontal treatment; present the results of the test and control groups, and  assessments of clinical periodontal parameters such as probing depth (PD), bleeding on probing (BOP) and clinical attachment level (CA). Exclusion criteria were local antibiotic therapy and trials not published in English.

Two researchers independently selected and screened the articles. Data bases were searched from July 1994 to August 2016. The included databases were MEDLINE, Cochrane Controlled Clinical Trial Register, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, CINAHL, Science Direct, and ISI Web of Knowledge, Scopus, and manually searched relevant specialist journals. Quality assessment was undertaken using the Jadad scale.

Results

The systematic Search found 3 papers out of 68 which fulfilled the inclusion criteria for meta-analysis. On the JADAD risk of bias assessment only 8/30 studies were evaluated as high quality.

Meta-analysis results (Primary outcomes)

Mean Difference Probing Depth (p = 0.0359   MD -0.32,   95% CI -0.50 – -0.14)
Mean Difference Clinical Attachment level (p = 0.0161   MD -0.22,   95% CI -0.39 – -0.06)
Mean Difference Bleeding on Probing (p = 0.446     MD -0.04,   95% CI -0.13– 0.06)

 Author’s Conclusion

“The results of our meta-analysis reveal the clinical benefits of systemic antibiotics as an adjunct to the non-surgical periodontal treatment of smokers. These clinical improvements, although statistically significant, appeared to be of little clinical relevance.”

Comments

In the discussion, the author goes to considerable length to explain the effectiveness for the adjunctive use of antibiotics in the periodontal treatment of smokers and to their credit also the lack of clinical relevance. There are three important points to be made here:

  • The degree of precision in the published mean difference of this paper is 0.005mm. The maximum precision possible with a standard periodontal probe is 0.5mm, and in the surgery the measurements are mostly taken as whole numbers. Mosteller described the issue this way:

“The number of significant figures gives a hint of accuracy. For example, 98.2o has three significant figures and might be regarded as correct to within 0.05o (One should not count on this level of accuracy.) Therefore, in these ambiguous circumstances, the author should tell what degree of accuracy is intended, as nearly as possible”(Mosteller 1992)

 

  • It is not an uncommon finding in primary research that the test groups and the trials time-frame are far too small to derive any precise/useful statistical results; this is something authors need to be addressed at the planning and protocol registration stage.

 

  • Additionally in the primary research the subjects continued to smoke throughout the duration of the trial, therefore it is hardly surprising there is no improvement in the results, the damaging effect of the smoking drowning out the benefit of the antibiotics. It is generally accepted that tobacco smoking remains the leading single risk to health in high-income North America and Western Europe by quite a large margin. (Lim et al. 2012).

Links

Primary Paper

Assem, N.Z. et al., 2017. Antibiotic therapy as an adjunct to scaling and root planing in smokers: a systematic review and meta-analysis. Brazilian Oral Research, 31, pp.1–15. Available at: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1806-83242017000100951&lng=en&tlng=en.


Additional references

Dietrich, T. et al., 2015. Smoking, Smoking Cessation, and Risk of Tooth Loss: The EPIC-Potsdam Study. Journal of dental research, 94(10), pp.1369–75.

Keestra, J.A.J. et al., 2014. Non-surgical periodontal therapy with systemic antibiotics in patients with untreated chronic periodontitis: A systematic review and meta-analysis. Journal of Periodontal Research, (32), pp.689–706.

Lim, S.S. et al., 2012. A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990-2010: A systematic analysis for the Global Burden of Disease Study 2010. The Lancet, 380(9859), pp.2224–2260.

Mosteller, F., 1992. Writing about numbers. In Medical uses of statistics. Boston: NEJM Books, pp. 375–89.

Rabelo, C.C. et al., 2015. Systemic antibiotics in the treatment of aggressive periodontitis. A systematic review and a Bayesian Network meta-analysis. Journal of Clinical Periodontology, 42(7), pp.647–657.

Zeng, J. et al., 2014. Reexamining the Association Between Smoking and Periodontitis in the Dunedin Study With an Enhanced Analytical Approach. Journal of Periodontology, 85(10), pp.1390–1397. Available at: http://dx.doi.org/10.1902/jop.2014.130577.

 

 

 

Advertisements

Oral care in nursing homes

imagesOne challenge to our future healthcare system will come from the care requirement of frail patients living in residential care. Data suggests that the size of the UK population aged over 65 will rise by 60% to 16 million over the next 25 years, 5% being over 85 years old (Batchelor 2015). 80% will end up live in some form of residential home, being looked after by professional staff rather than family members (Broad et al. 2013). Two major barriers exist:

  • Residents responsive behaviour – defined as physical or verbal actions, such as grabbing, screaming, and resisting care, in response to a negatively perceived stimulus.
  • Residents lack of motivation or ability to perform their own oral hygiene.

The objective of this review is to evaluate the effectiveness of strategies that nursing home care providers can apply to either prevent/overcome residents’ responsive behaviours to oral care, or enable/motivate residents to perform their own oral care.

Methods

The review followed the PRISMA statement (the protocol was also registered on the International Prospective Register of Systematic Reviews (PROSPERO) database.
Searches were carried by two independent researchers using Medline, Embase, Evidence Based Reviews-Cochrane Central Register of Controlled Trials, CINAHL, and Web of Science. Databases were searched up to April 2016 with no language restrictions, and manual searches were also carried out in the relevant major journals.

Inclusion criteria were as follows: Qualitative observational studies and mixed-methods studies including reviews relating to strategies that formal care providers can use to motivate oral health care and overcome responsive behaviour for frail older adults in residential care. Exclusion criteria were non-empirical and qualitative research, healthy or independent residents or care provided by family, students or managers.

Study outcomes were resident’s oral health scores, self-performed oral care, responsive behaviour and level of staff assistance. 
Quality appraisal was carried out by two independent reviewers using the Quality Assessment Tool for Quantitative studies and Estabrooks Quality Assessment and Validity Tools for Cross Sectional Studies.

Results

  • From 7362 records only 7 studies fulfilled the inclusion criteria, four of which report different aspects of one research project. Therefore. 3 prospective cohort studies and 1 cross-sectional study were included.
  • Methodological quality was low/moderate for one study and weak for three studies.
  • Plaque index scores reduced by approximately 40%
  • Bleeding index scores reduced by approximately 35%
  • Denture plaque scores reduced by 23%
  • Resistance to care reduced by approximately 45%

Conclusions

The authors concluded: –

Potentially promising strategies are available that nursing home care providers can apply to prevent/overcome residents’ responsive behaviours to oral care or to enable/motivate residents to perform their own oral care. However, studies assessing these strategies have a high risk for bias. To overcome oral health problems in nursing homes, care providers will need practical strategies whose effectiveness was assessed in robust studies.

Comments

This review highlights the lack of studies relating to the important issue of oral health maintenance of frail older patients. As our population ages this problem is only going to increase in complexity. Though the results were good but the sample sizes are very small (5,7,13 and 97 patients respectively) and the duration of the study was very short (2-8 weeks).

Other longer-term observational studies not identified in this review of routine care have shown a degrading of oral hygiene irrespective of maintenance regime, and regression to 40% had unacceptable hygiene, high levels of resistance and cleaning being left largely undone with assisted tooth brushing times as low as 16 seconds (Willumsen et al. 2012; De Visschere et al. 2015; Carter et al. 2009). The reasons being increased frailty and cognitive capacity over time with the average patient staying in high dependency residential care for 16 months, compounded with high turn-over of trained care staff.   In addition the recent Cochrane review by Albrecht et al (Dental Elf – Oct 10th – 2016):-

found insufficient evidence to draw robust conclusions about the effects of oral health educational interventions for nursing home staff and residents.

Links

Original Post: Dental Elf – June 30th – 2017

Primary paper

Hoben M, Kent A, Kobagi N, Huynh KT, Clarke A, Yoon MN. Effective strategies to motivate nursing home residents in oral care and to prevent or reduce responsive behaviors to oral care: A systematic review. PLoS One. 2017 Jun 13;12(6):e0178913. doi:10.1371/journal.pone.0178913. eCollection 2017. PubMed PMID: 28609476.

Review Protocol on PROSPERO

Other references

Batchelor, P. The changing epidemiology of oral diseases in the elderly, their growing importance for care and how they can be managed. Age and Ageing, 2015 44(6), pp.1064–1070.

Broad JB, Gott M, Kim H, Boyd M, Chen H, Connolly MJ. Where do people die? An international comparison of the percentage of deaths occurring in hospital and residential aged care settings in 45 populations, using published and available statistics. Int J Public Health. 2013 Apr;58(2):257-67. doi: 10.1007/s00038-012-0394-5. Epub 2012 Aug 15. Erratum in: Int J Public Health. Int J Public Health. 2013 Apr;58(2):327. PubMed PMID: 22892713.

Carter, K.D. et al., 2009. Caring for Oral Health in Australia Residential Care. Australian Institute of  Health and Welfare, (48), pp.1–53.

De Visschere L, de Baat C, De Meyer L, van der Putten GJ, Peeters B, Söderfelt B, Vanobbergen J. The integration of oral health care into day-to-day care in nursing homes: a qualitative study. Gerodontology. 2015 Jun;32(2):115-22. doi: 10.1111/ger.12062. Epub 2013 Jun 20. PubMed PMID: 23786637.

Willumsen T, Karlsen L, Naess R, Bjørntvedt S. Are the barriers to good oral hygiene in nursing homes within the nurses or the patients? Gerodontology. 2012 Jun;29(2):e748-55. doi: 10.1111/j.1741-2358.2011.00554.x. Epub 2011 Oct 24. PubMed PMID: 22023222.