Use of adjuncts in periodontal treatment for patients with diabetes

Background + Aims

• Studies have shown that initial periodontal therapy, such as scaling and root planing (SRP), either alone or combined with adjunctive treatments like antimicrobials, can improve clinical outcomes in both diabetic and non-diabetic individuals.
• These benefits are thought to arise from reducing pathogenic bacteria and establishing a microbiota conducive to periodontal health.
• Maintenance programs, including repeated SRP, can help sustain these improvements, although persistent deep pockets, angular defects, and furcation involvements may not respond well to SRP alone. In such cases, surgical approaches or systemic antimicrobials have been proposed to enhance treatment outcomes, especially for unresponsive sites.
• Surgical methods like access flap techniques have demonstrated better reductions in probing pocket depth (PPD) and clinical attachment level (CAL) gains compared to non-surgical treatments.
• While protocols for unresponsive pockets in non-diabetic individuals exist, data on type 2 diabetes patients remain scarce.
• This pilot study evaluates surgical and non-surgical debridement, with systemic metronidazole and amoxicillin, for treating residual pockets in type 2 diabetics using a split-mouth design.

Materials + Methods

• This prospective, split-mouth, randomised controlled clinical study (RCT) involved 21 type 2 diabetic patients (aged 42–67) with generalised chronic periodontitis and residual pockets.
• Inclusion criteria included:
  • Diagnosis of type 2 diabetes for ≥6 years
  • Age >40
  • ≥15 teeth
  • ≥30% sites with PPD and CAL ≥4 mm
• Exclusion criteria included:
  • Pregnancy
  • Recent smoking history
  • Antimicrobial use
  • Systemic conditions other than diabetes.
• All subjects underwent initial SRP without antimicrobials and were enrolled in supportive periodontal therapy.
• After 12 months, 21 patients with at least two non-adjacent residual pockets per half-contralateral quadrant were included.
Residual pockets were defined as sites with PPD ≥5 mm and BOP requiring additional treatment.
• 
Quadrants were randomly assigned via a computer-generated table to surgical or non-surgical debridement. Surgical debridement involved sulcular incisions, full-thickness flap elevation, granulation tissue removal, and meticulous SRP, followed by flap repositioning and suturing. Non-surgical debridement consisted of SRP without flap elevation.
• Both groups received systemic metronidazole (400 mg) and amoxicillin (500 mg) x3/daily for 10 days.
• Chlorhexidine mouthwash and standardized toothpaste were provided, and compliance was monitored.
• 
Clinical parameters, including PPD, CAL, plaque index, BOP, and marginal bleeding, were assessed at baseline, 3, and 6 months.
• Gingival crevicular fluid (GCF) was sampled from residual pockets for cytokine analysis using ELISA.
• Data were analyzsd using parametric methods, with a significance level of p < 0.05.

Results

• This study involved 21 type 2 diabetic subjects (13 males, 8 females; mean age 53.2 ± 9.1 years) with generalised chronic periodontitis and residual pockets.
• The participants had a mean HbA1c of 11.3 ± 2.3% and a diabetes duration of 7.1 ± 0.9 years.
• No dropouts occurred, and adverse effects were minimal, with 6 participants reporting mild side effects, including diarrhoea and headache.
• At baseline, there were no significant differences in clinical parameters between the surgical debridement and non-surgical debridement groups. Both therapies significantly reduced PPD, BOP and residual pocket counts over 3 and 6 months (p < 0.05).
• Surgical debridement resulted in a greater mean PPD reduction and significant improvements in CAL compared to non-surgical debridement (p < 0.05). However, no differences between groups were observed for residual pocket outcomes or GCF parameters, including PPD, CAL, and cytokine concentrations.
• Immunological analysis showed no baseline differences between groups in cytokine levels. Surgical debridement induced significant increases in IFN-γ, IL-4, and IL-17 at 6 months (p < 0.05), likely due to surgical tissue trauma, while NSD showed no significant cytokine changes.
• Both surgical and non-surgical debridement were effective in managing residual pockets in diabetic subjects, but surgical debridement demonstrated superior clinical outcomes in PPD and CAL reduction. However, the hypothesis that surgical debridement with systemic antimicrobials would yield better results than non-surgical debridement was rejected, as overall differences between groups were minimal.

Limitations

• The timing of systemic antimicrobials and chlorhexidine rinsing varied between the surgical debridement and non-surgical debridement groups, potentially influencing the outcomes. Subjects received antimicrobials for 10 days following surgical treatment but only 4 days after non-surgical treatment. Chlorhexidine rinsing was prescribed for 2 weeks after surgical treatment but only 8 days after non-surgical treatment.
• The examiner could identify which quadrants underwent which treatment based on visible surgical changes, and patients could also distinguish between the treatments. This lack of blinding introduces potential bias in clinical and subjective assessments.
• The study did not include a non-diabetic control group, limiting the ability to evaluate whether the heightened cytokine levels post-surgical debridement were specific to the diabetic population or reflective of a general delayed wound healing and inflammation process.
• The study was limited to a 6-month follow-up period, which does not provide insights into the long-term stability of the clinical and immunological outcomes.