Oral and systemic health: is there a "new" link with COVID-19?

OBJECTIVES: The objective of the present narrative review was to evaluate the evidence of a possible association between periodontitis and COVID-19, and its biological plausibility, using as models the potential associations with cardiovascular diseases, diabetes, and some respiratory diseases. METHODS: A recent systematic review was used as main reference to explore the associations of periodontitis with different respiratory diseases, including COVID-19, following two focussed questions: a PECOS question, aimed to explore epidemiological evidence, and a PICOS question, designed to explore the evidence derived from intervention studies. In addition to that evidence, other relevant scientific documents, including consensus papers, were carefully selected and appraised. FINDINGS: Convincing evidence was found to support the association of periodontitis and cardiovascular diseases, diabetes, and some respiratory diseases. The biological plausibility behind those associations is based on four factors: (1) bacteraemia of oral bacteria and periodontal pathogens, (2) increased systemic inflammation, (3) common genetic factors, and (4) common environmental risk factors. Limited initial evidence is available to support an association between periodontitis and COVID-19 complications. Among the proposed factors to explain the suggested association, a combination of the previously mentioned factors, plus additional factors related with SARS-CoV-2 characteristics and pathogenicity, has been suggested. CONCLUSIONS: Initial evidence suggests that periodontitis may be associated with a more severe COVID-19 and with a higher risk of death due to COVID-19. CLINICAL RELEVANCE: Due to the possible association between periodontitis and an increased severity for COVID-19, additional efforts should be made to improve oral and periodontal health, including the promotion of oral healthy habits, such as oral hygiene.

Efficacy of adjunctive therapies in patients with gingival inflammation: A systematic review and meta-analysis.

AIM: To evaluate the efficacy of adjunctive therapies in reducing gingivitis and plaque by means of a systematic review of randomized clinical trials (RCTs). MATERIAL AND METHODS: A search protocol was designed to identify 6-month RCTs that investigated the efficacy of adjuncts to mechanical plaque control on gingivitis and plaque. Following screening, relevant information was extracted, and quality and potential risk of bias were estimated. Mean treatment differences were calculated to obtain standardized mean differences and weighted mean differences (SMD and WMD) as appropriate. RESULTS: Meta-analyses included 70 studies of adjunctive antiseptics. Compared with mechanical plaque control alone, adjuncts yielded statistically significant reductions in gingival index (n = 72; SMD = -1.268; 95% CI [-1.489; -1.047]; p < .001; I2  = 96.2%), bleeding (%) (n = 26, WMD=-14.62%; 95% CI [-18.01%; -11.23%]; p < .001; I2  = 95.1%), plaque index (n = 93, SMD = -1.017; 95% CI [-1.194; -0.840]; p < .001; I2  = 95.3%) and plaque (%) (n = 23; WMD = -18.20%; 95% CI [-24.00%; -12.50%]; p < .001; I2  = 96.9%). Mouthrinses resulted in greater reductions in per cent plaque compared with dentifrices (meta-regression, coefficient = 13.80%; 95% CI [2.40%; 25.10%]; p = .020). The antiseptic agents were similarly effective in reducing gingivitis and plaque in patients with dental plaque-induced gingivitis (intact periodontium) or previously treated periodontitis with gingival inflammation. CONCLUSION: Adjunctive antiseptics in mouthrinses and dentifrices provide statistically significant reductions in gingival, bleeding and plaque indices.

Is the oral cavity relevant in SARS-CoV-2 pandemic?

OBJECTIVES: Recent scientific evidences suggest a relevant role of the oral cavity in the transmission and pathogenicity of SARS-CoV-2. METHODS: A literature search was performed in PubMed, up to April 30, 2020, focusing on SARS-CoV-2, COVID-19, oral cavity, and antimicrobial agents. RESULTS: Oral viral load of SARS-CoV-2 has been associated with the severity of COVID-19, and thus, a reduction in the oral viral load could be associated with a decrease in the severity of the condition. Similarly, a decrease in the oral viral load would diminish the amount of virus expelled and reduce the risk of transmission, since (i) during the first 10 days, the virus mainly accumulates at the nasal, oral, and pharyngeal area; (ii) the number of angiotensin-converting enzyme (ACE2) receptor is greater in the salivary glands as compared with the lungs; and (iii) salivary droplets represent the most relevant transmission route. To reduce the oral viral load, antiseptic agents may be used, although the evidence on its efficacy is indirect and weak. CONCLUSIONS: Antiseptic mouth rinses, such as those containing cetylpyridinium chloride or povidone-iodine, may be able to decrease the severity of COVID-19 by reducing oral viral load in infected subjects and decreasing the risk of transmission by limiting viral load in droplets, generated in normal life, or in aerosols, produced during dental procedures. Well-designed clinical and preclinical research must be conducted to support these hypotheses. CLINICAL RELEVANCE: Antiseptic mouth rinses may help in decreasing the severity of COVID-19 and in reducing the risk of transmission.

Efficacy of adjunctive anti-plaque chemical agents in managing gingivitis: A systematic review and network meta-analyses.

AIM: The aim of this network meta-analysis (NMA) was to compare the efficacy of different oral hygiene products for chemical biofilm control, in 6-month home-use, randomized clinical trials (RCTs), in terms of changes in gingival index (GI). MATERIAL AND METHODS: Six-month RCTs assessing GI were identified and screened for inclusion. Relevant information was extracted, and quality and potential risk of bias were estimated. Mean differences between baseline and end were calculated to obtain standardized mean differences (SMDs). NMA protocols were applied to assess direct and indirect comparisons among products using Löe & Silness GI, modified GI and gingival severity index. RESULTS: Fifty-three papers were included, 19 studies for mouth rinses, 32 for dentifrices, comprising data from 5,775 and 2,682 subjects, respectively. When ranking treatments, similar results were observed for all tested dentifrices, with the lowest effect observed for sanguinarine and baking soda. For mouth rinses, essential oils, triclosan-copolymer, chlorhexidine (at concentrations ≥ 0.10%) and cetylpyridinium chloride (>0.05%) demonstrated the greatest effect. CONCLUSION: Although NMA revealed significant differences when comparing placebo versus some active agents, when comparing among active agents, no differences were found for dentifrices, while mouth rinses containing essential oils showed the greatest effect on GI scores.

Efficacy of adjunctive anti-plaque chemical agents: a systematic review and network meta-analyses of the Turesky modification of the Quigley and Hein plaque index.

AIM: The aim of this systematic review and network meta-analysis (NMA) was to compare the efficacy of different anti-plaque chemical agents, in 6-month, home-use, randomized clinical trials (RCTs), in terms of plaque index (PlI) changes. MATERIAL AND METHODS: RCTs assessing PlI were identified, screened, and evaluated for inclusion. Relevant information was extracted, and quality and risk of bias were assessed. Mean differences between baseline-end were calculated to obtain weighted mean differences and 95% confidence intervals. NMA protocols were applied to assess direct and indirect comparisons among products using Turesky PlI. RESULTS: Eighty-three papers were included: 49 examined dentifrices, 32 mouthrinses and 2 both. The NMA analysed 51 studies including data from 4242 and 4180 subjects for dentifrices and mouthrinses respectively. For dentifrices, triclosan-copolymer and chlorhexidine showed the greatest effect, with significant differences when compared with stannous fluoride. For mouthrinses, essential oils and chlorhexidine showed the greatest effect, with significant differences when compared with delmopinol, alexidine and cetylpyridinium chloride. CONCLUSION: Within the limitations of this study (including the severe imbalance in the amount of evidence), dentifrices containing triclosan-copolymer or chlorhexidine and mouthrinses containing essential oils or chlorhexidine showed the greatest effect on PlI scores as assessed with NMA.

Efficacy of adjunctive anti-plaque chemical agents in managing gingivitis: a systematic review and meta-analysis.

AIM: The aim of this systematic review was to evaluate the efficacy of anti-plaque chemical formulations for managing gingivitis, in 6-month, home-use, randomised clinical trials (RCTs). MATERIAL AND METHODS: A protocol was designed, including inclusion and exclusion criteria to identify RCTs assessing gingival and/or bleeding indices. Electronic and hand-searches identified relevant papers, which were screened and evaluated for inclusion. Full-papers were retrieved and relevant information was extracted (also plaque indices), including quality and risk of bias. Mean treatment effects were calculated to obtain weighted mean differences (WMD) and 95% confidence intervals. RESULTS: After the process of screening and selection, 87 articles with 133 comparisons, were included in the review. The additional effects of the tested products were statistically significant in terms of Löe & Silness gingival index (46 comparisons, WMD -0.217), modified gingival index (n = 23, -0.415), gingivitis severity index (n = 26, -14.939%) or bleeding index (n = 23, -7.626%), with significant heterogeneity. For plaque, additional effects were found for Turesky (66 studies, WMD -0.475), Silness & Löe (n = 26, -0.109), and plaque severity (n = 12, -23.4%) indices, with significant heterogeneity. CONCLUSION: Within the limitations of the present study, formulations with specific agents for chemical plaque control provide statistically significant improvements in terms of gingival, bleeding and plaque indices.

Effect of professional mechanical plaque removal on secondary prevention of periodontitis and the complications of gingival and periodontal preventive measures: consensus report of group 4 of the 11th European Workshop on Periodontology on effective prevention of periodontal and peri-implant diseases.

BACKGROUND AND AIMS: The scope of this working group was to review: (1) the effect of professional mechanical plaque removal (PMPR) on secondary prevention of periodontitis; (2) the occurrence of gingival recessions and non-carious cervical lesions (NCCL) secondary to traumatic tooth brushing; (3) the management of hypersensitivity, through professionally and self administered agents and (4) the management of oral malodour, through mechanical and/or chemical agents. RESULTS AND CONCLUSIONS: Patients undergoing supportive periodontal therapy including PMPR showed mean tooth loss rates of 0.15 ± 0.14 teeth/year for 5-year follow-up and 0.09 ± 0.08 teeth/year (corresponding to a mean number of teeth lost ranging between 1.1 and 1.3) for 12-14 year follow-up. There is no direct evidence to confirm tooth brushing as the sole factor causing gingival recession or NCCLs. Similarly, there is no conclusive evidence from intervention studies regarding the impact of manual versus powered toothbrushes on development of gingival recession or NCCLs, or on the treatment of gingival recessions. Local and patient-related factors can be highly relevant in the development and progression of these lesions. Two modes of action are used in the treatment of dentine hypersensitivity: dentine tubule occlusion and/or modification or blocking of pulpal nerve response. Dentifrices containing arginine, calcium sodium phosphosilicate, stannous fluoride and strontium have shown an effect on pain reduction. Similarly, professionally applied prophylaxis pastes containing arginine and calcium sodium phosphosilicate have shown efficacy. There is currently evidence from short-term studies that tongue cleaning has an effect in reducing intra-oral halitosis caused by tongue coating. Similarly, mouthrinses and dentifrices with active ingredients based on Chlorhexidine, Cetylpyridinium chloride and Zinc combinations have a significant beneficial effect.

Efficacy of periodontal plastic procedures in the treatment of multiple gingival recessions.

OBJECTIVE: To systematically review the efficacy of periodontal plastic procedures (PPP) in the treatment of multiple gingival recessions (MGR). METHODS: Randomized clinical trials (RCT) on MGR treatment with at least 6 months duration were identified through electronic databases and hand-searched journals. Primary outcomes were complete root coverage (CRC) and percentage of root coverage (PRC). Weighted means and forest plots were calculated for all PPP. Subgroup analysis was performed according to the type of flap. A Bayesian network meta-analysis (NM) on secondary outcomes was also performed. RESULTS: Nine trials including 208 subjects and 858 recessions were identified. CRC after PPP was 24-89%. Mean weighted PRC was 86.27% (95% CI 80.71-91.83; p < 0.01). Heterogeneity of the literature prevented inter-techniques comparison. Coronally advanced flap (CAF) shows the higher variability in terms of CRC. Modified CAF and tunnel approaches show higher level of CRC. The NM suggests that CAF plus graft showed the higher probability of being the best treatment. CONCLUSIONS: Limited evidence is available for MGR coverage. PPP are associated with high level of efficacy, in terms of PRC, and high variability of CRC. Indirect evidence indicates that CAF may benefit from newer variations of the technique and by the additional use of grafting.

Periodontal bacterial invasion and infection: contribution to atherosclerotic pathology.

OBJECTIVE: The objective of this review was to perform a systematic evaluation of the literature reporting current scientific evidence for periodontal bacteria as contributors to atherosclerosis. METHODS: Literature from epidemiological, clinical and experimental studies concerning periodontal bacteria and atherosclerosis were reviewed. Gathered data were categorized into seven "proofs" of evidence that periodontal bacteria: 1) disseminate from the oral cavity and reach systemic vascular tissues; 2) can be found in the affected tissues; 3) live within the affected site; 4) invade affected cell types in vitro; 5) induce atherosclerosis in animal models of disease; 6) non-invasive mutants of periodontal bacteria cause significantly reduced pathology in vitro and in vivo; and 7) periodontal isolates from human atheromas can cause disease in animal models of infection. RESULTS: Substantial evidence for proofs 1 to 6 was found. However, proof 7 has not yet been fulfilled. CONCLUSIONS: Despite the lack of evidence that periodontal bacteria obtained from human atheromas can cause atherosclerosis in animal models of infection, attainment of proofs 1 to 6 provides support that periodontal pathogens can contribute to atherosclerosis.

The Underestimated Problem of Intra-Oral Halitosis in Dental Practice: An Expert Consensus Review.

Approximately 90% of halitosis cases originate within the oral cavity (intra-oral halitosis). With a focus on intra-oral halitosis, this narrative review article provides a current summary of the epidemiology, diagnosis and management of halitosis and discusses practical considerations for healthcare professionals (HCPs), including dentists, dental hygienists, general practitioners, community pharmacists, nurses and medical specialists. MEDLINE and PubMed were searched up to 31 December 2019. Additional information was sourced from reference lists of relevant published literature. Full-text articles which reported on the epidemiology, diagnosis and management of halitosis were considered for inclusion. Halitosis affects substantial numbers of individuals globally and is an underestimated problem in dental practice. Current estimates of the prevalence of halitosis, in addition to diagnostic methods and management considerations for halitosis, are discussed. Although not a life-threatening condition, halitosis has a significant impact on patients' quality of life and can result in psychological consequences including social, professional and affective limitations. Using a simple step-wise approach for diagnosis and treatment, dentists and dental hygienists are ideally placed to respond to an initial consultation for halitosis.

Antimicrobial therapy in periodontitis: the use of systemic antimicrobials against the subgingival biofilm.

OBJECTIVES: The aim was to answer three relevant questions: can systemic antimicrobials be efficacious if the biofilm is not disrupted? Can the type of debridement of the subgingival biofilm impact upon the clinical outcomes of the adjunctive antimicrobial therapy? Is the efficacy of the adjunctive systemic antimicrobial therapy dependent on the quality of the debridement of the subgingival biofilm and the sequence debridement-antibiotic usage? MATERIAL AND METHODS: Relevant papers were searched, critically analysed and their data were extracted. RESULTS: For the first question, studies assessing susceptibility of bacteria in biofilms, and clinical studies evaluating systemic antimicrobials as monotherapy, were reviewed. For the second question, clinical studies comparing systemic antimicrobials as adjuncts to non-surgical debridement or to periodontal surgery and clinical trials using systemic antibiotics with periodontal surgery were evaluated. For the third question, a previous systematic review was updated. CONCLUSION: If systemic antimicrobials are indicated in periodontal therapy, they should be adjunctive to mechanical debridement. There is not enough evidence to support their use with periodontal surgery. Indirect evidence suggests that antibiotic intake should start on the day of debridement completion, debridement should be completed within a short time (preferably <1 week) and with an adequate quality, to optimize the results.

A combined therapeutic approach to manage oral halitosis: a 3-month prospective case series.

BACKGROUND: Clinical research assessing different therapeutic protocols aimed at treating oral halitosis is scarce. The aim of this study was to evaluate the effects of a combined mechanical and pharmacological approach to treat oral halitosis on clinical and microbiological outcomes on patients followed for 3 months. METHODS: Nineteen subjects with oral malodor participated. At baseline, all subjects completed a questionnaire and carried out an examination including full-mouth organoleptic and volatile sulfur compound (VSC) levels and the Winkel tongue coating index. Standard periodontal outcome variables were assessed at six teeth. Standardized microbiological samples of subgingival plaque, unstimulated saliva, and tongue coating were obtained for culture analysis. The treatment protocol included supragingival prophylaxis; instructions in oral hygiene (toothbrushing, interproximal cleaning, and tongue scraping); and gargling with a mouthrinse containing chlorhexidine, cetylpiridinium chloride, and zinc lactate. The same outcome variables were registered 1 and 3 months after baseline. RESULTS: Statistically significant reductions in organoleptic scores (P <0.001), VSC levels (P <0.05), and tongue coating index (P <0.05) were observed after 1 and 3 months. Mean probing depth and plaque levels also demonstrated significant reductions after 3 months (P <0.05). Total anaerobic counts were significantly reduced at all three locations after 1 month (P <0.05), and in samples from tongue coating and subgingival plaque at 3 months (P <0.05). Aerobic counts were significantly reduced in saliva at 1 month (P <0.05), and the anaerobic/aerobic ratio significantly increased in the tongue samples. Among the selected pathogens evaluated, Porphyromonas gingivalis was the most affected of the three microflora evaluated. CONCLUSIONS: The evaluated therapeutic approach demonstrated its efficacy in the management of oral halitosis, demonstrating statistically significant improvements in both organoleptic and VSC values at 1 and 3 months. The proposed clinical protocol significantly affected the microbial composition in tongue coating, saliva, and subgingival microflora.

[Halitosis management by the general dental practitioner- results of an International Consensus Workshop*]. / Halitosismanagement für die Zahnarztpraxis. Ergebnisse eines internationalen Konsunsus-Workshops*.

Clinical investigations on patients suffering from halitosis clearly reveal that in the vast majority of cases the source for an offensive breath odor can be found within the oral cavity (90%). Based on these studies, the main sources for intra-oral halitosis where tongue coating, gingivitis/periodontitis and a combination of the two. Thus, it is perfectly logical that general dental practitioners (GDPs) should be able to manage intra-oral halitosis under the conditions found in a normal dental practice. However, GDPs who are interested in diagnosing and treating halitosis are challenged to incorporate scientifically based strategies for use in their clinics. Therefore, the present paper summarizes the results of a consensus workshop of international authorities held with the aim to reach a consensus on general guidelines on how to assess and diagnose patients’ breath odor concerns and general guidelines on regimens for the treatment of halitosis.

Comparative effects of different chlorhexidine mouth-rinse formulations on volatile sulphur compounds and salivary bacterial counts.

AIM: To compare five different commercial mouth rinses with chlorhexidine (CHX) with respect to their anti-halitosis effect and anti-microbial activity on salivary bacterial counts, following a standardised research protocol. And secondly, to validate the study model proposed in the evaluation of patients suffering from halitosis. PATIENTS AND METHODS: Ten volunteers, with a healthy oral status, were enrolled in a double-blind, cross-over design, using sterile saline as negative control and five CHX-containing mouth rinses: 0.12% CHX alone (CHX+NO), plus alcohol (CHX+ALC), plus 0.05% cetylpiridinium chloride (CHX+CPC), plus sodium fluoride (CHX+NaF), and 0.05% CHX plus 0.05% CPC, plus 0.14% zinc lactate (CHX+Zn). The levels of whole-mouth volatile sulphur compounds (VSCs) were measured by means of a sulphide monitor at baseline, 1 and 5 h after rinsing with the assigned product. Baseline measurements also included an organoleptic assessment and the recording of the tongue-coating index. Aerobic and anaerobic salivary bacterial counts were also obtained by collecting unstimulated saliva samples at the same evaluation times, and processed by culturing techniques. Analysis of variance was used to evaluate whether significant differences existed among groups, at each evaluation point, or in changes between evaluations. RESULTS: No significant differences were detected at baseline, with VSC levels ranging between 190 and 227 parts per billion (p.p.b.) After rinsing, VSC levels were reduced with all products (except saline), after 1 h. Significant differences at 1 h were detected (p=0.04), corresponding to a lower amount of p.p.b. (109) in (CHX+Zn) as compared with the other groups (except CHX+NO). At 5 h, VSC levels were lower for CHX+CPC and CHX+Zn (155 and 169, respectively), while the other groups showed levels higher than 220 p.p.b. With respect to aerobic salivary bacterial counts, CHX+CPC demonstrated the lowest percentage of survival (6% after 1 h and 18% after 5 h). For anaerobic bacterial counts, again CHX+CPC demonstrated the lowest percentage of survival (10% at 1 h and 23% at 5 h), together with CHX+ALC (18% of survival at 5 h). However, salivary counts and VSCs were only significantly correlated at baseline, but not after treatment. CONCLUSION: Important differences can be expected from different CHX formulations, in relation to both their anti-halitosis effect and anti-microbial activity in saliva. Formulations that combine CHX and CPC achieved the best results, and a formulation combining CHX with NaF resulted in the poorest.

Differences in antimicrobial activity of four commercial 0.12% chlorhexidine mouthrinse formulations: an in vitro contact test and salivary bacterial counts study.

AIM: To evaluate the in vitro and in vivo antimicrobial activity of four commercial 0.12% chlorhexidine mouthrinses. MATERIAL AND METHODS: The in vitro antimicrobial activity test consisted in a modified contact test where 20 selected bacterial species were tested during 1 min with each test product. After the contact, the inoculum was cultured, and the results were expressed in terms of survival/resistance and the percentage of survival as compared to a saline control. The in vivo test consisted of a double-blind, randomized, crossover salivary bacterial counts study. 10 volunteers rinsed during 1 min with each tested product. Saliva samples were obtained before rinsing, and after 5 min, and 1, 3, 5 and 7 h. These samples were cultured both aerobically and anaerobically. Percentages of survival, in regard to baseline, were calculated for each time point. Comparisons among products were tested using anova and selected paired t-test. RESULTS: The in vitro contact test showed no survival in any tested species with CHX+CPC, while three species (Lactobacillus casei, Streptococcus mitis and Peptostreptococcus micros) were resistant to the other three products. CHX and CHX+NaF demonstrated additional resistant species (three and four species, respectively). The in vivo salivary bacterial counts test showed higher reductions of CHX+CPC and CHX+ALC in aerobic and anaerobic bacteria, lasting for 5 h. Significant differences were detected at multiple time points, when these two products were compared both with the control and the other tested products. CONCLUSION: Important differences in activity, among 0.12% CHX products, were detected by both in vitro and in vivo tests. The formulation with alcohol was more active than those without alcohol, excepting the formulation with CHX+CPC, in which the reformulation and addition of CPC not only compensate but rather increase the antimicrobial activity.

A systematic review on the effect of systemic antimicrobials as an adjunct to scaling and root planing in periodontitis patients.

BACKGROUND: Scaling and root planing (SRP) are the bases of non-surgical therapy in the treatment of periodontitis. However, results from this therapy are often unpredictable and dependable from many different factors. OBJECTIVES: The aim of this systematic review was to evaluate the effectiveness of the adjunctive use of systemic antimicrobials with scaling and root planing (SRP) vs. SRP alone in the treatment of chronic (CP) or aggressive periodontitis (AgP). SEARCH STRATEGY: Use of computerized databases, namely MEDLINE, the Cochrane Oral Health Group Specialty Trials Register and EMBASE; reference lists from relevant articles were hand-searched; and a hand-search of selected journals until April 2001. SELECTION CRITERIA: Studies were selected if they were designed as controlled clinical trials in which systemically healthy patients with either AgP or CP were treated with SRP plus systemic antimicrobials in comparison with SRP alone or with placebo, for a minimum of 6 months. Main outcome measures were clinical attachment level (CAL) change and probing pocket depth (PPD) change. DATA COLLECTION AND ANALYSIS: Two reviewers extracted independently information regarding quality and study characteristics, in duplicate. Kappa scores determined their agreement. Main results were collected and grouped by drug, disease and PPD category. For the quantitative data synthesis, the data was pooled (when mean differences and standard errors were available), and either a Fixed Effects or Random Effects meta-analysis was used for the analysis. RESULTS: After an initial selection, 158 papers were identified by the manual and electronic searches; 25 papers were eligible for inclusion. Their quality assessment showed that randomization and allocation concealment methods were seldom reported and blindness was usually not defined clearly. In general, selected studies showed high variability and lack of relevant information for an adequate assessment. Overall, SRP plus systemic antimicrobial groups demonstrated better results in CAL and PPD change than SRP alone or with placebo groups. Only limited meta-analyses could be performed, due to the difficulties in pooling the studies and the lack of appropriate data. This analysis showed a statistically significant additional benefit for spiramycin (PPD change) and amoxicillin/metronidazole (CAL change) in deep pockets. CONCLUSION: Systemic antimicrobials in conjunction with SRP, can offer an additional benefit over SRP alone in the treatment of periodontitis, in terms of CAL and PPD change, and reduced risk of additional CAL loss. However, differences in study methodology and lack of data precluded an adequate and complete pooling of data for a more comprehensive analyses. It was difficult to establish definitive conclusions, although patients with deep pockets, progressive or 'active' disease, or specific microbiological profile, can benefit more from this adjunctive therapy.