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Microbiological Outcomes from Different Periodontal Maintenance Interventions: a Systematic Review

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Microbiological Outcomes from Different Periodontal Maintenance Interventions: a Systematic Review SYSTEMAIC REVIEW Periodontics Microbiological outcomes from different periodontal maintenance interventions: a systematic review Patricia Daniela Melchiors ANGST(a) Abstract: This study aimed to investigate the differences in the Amanda Finger STADLER(b) subgingival microbiological outcomes between periodontal patients Rui Vicente OPPERMANN(c) Sabrina Carvalho GOMES(c) submitted to a supragingival control (SPG) regimen as compared to subgingival scaling and root planing performed combined with supragingival debridement (SPG + SBG) intervention during the (a) Universidade Federal de Pelotas – UFPEL, periodontal maintenance period (PMP). A systematic literature search Dental School, Department of Semiology using electronic databases (MEDLINE and EMBASE) was conducted and Clinic, Pelotas, RS, Brazil. looking for articles published up to August 2016 and independent of (b) Augusta University, The Dental College language. Two independent reviewers performed the study selection, of Georgia, Department of Periodontics, quality assessment and data collection. Only human randomized or Augusta, GA, United States of America. non-randomized clinical trials with at least 6-months-follow-up after (c) Universidade Federal do Rio Grande do periodontal treatment and presenting subgingival microbiological Sul – UFRGS, Dental School, Department of Conservative Dentistry, Porto Alegre, RS, Brazil. outcomes related to SPG and/or SPG+SBG therapies were included. Search strategy found 2,250 titles. Among these, 148 (after title analysis) and 39 (after abstract analysis) papers were considered to be relevant. Finally, 19 studies were selected after full-text analysis. No article had a direct comparison between the therapies. Five SPG and 14 SPG+SBG studies presented experimental groups with these respective regimens and were descriptively analyzed while most of the results were only presented graphically. The results showed that both SPG and SPG+SBG protocols of PMP determined stability in the microbiological results Declaration of Interest: The authors certify along time. Nevertheless, new studies comparing these interventions in that they have no commercial or associative interest that represents a conflict of interest in PMP are needed, especially if the limitations herein discussed could be connection with the manuscript. better controlled. Keywords: Dental Plaque; Microbiology; Root Planing; Review. Corresponding author: Patricia D.M. Angst Email: [email protected] Introduction The literature has clearly shown that the maintenance of periodontal results after an adequate therapy is delivered depends on the quality of https://doi.org/10.1590/1807-3107BOR-2017.vol31.0033 the supragingival plaque control (SPG).1,2,3,4,5 However, during the past 20 years the subgingival scaling and root planing (SBG) has been associated to that control and this association (SPG+SBG) been recognized as the choice therapy during periodontal maintenance period (PMP).6,7,8 Nevertheless, Submitted: Nov 24, 2016 studies comparing this combination to other protocols were not available Accepted for publication: Mar 21, 2017 Last revision: Mar 27, 2017 until recently when a clinical study9 and two systematic reviews10,11 suggested that the SPG biofilm control alone might be the choice during PMP. The Braz. Oral Res. 2017;31:e33 1 Microbiological outcomes from different periodontal maintenance interventions: a systematic review authors showed no clinical outcomes benefits from study; prospective study; supportive periodontal care; the addition of the subgingival scaling (SPG + SBG). periodontal maintenance, and microbiology. Microbiological composition of the subgingival A manual search of the reference list from narrative area after therapy as well is an issue of discussion. and systematic reviews studies, as well as the It is suggested that microbiological differences bibliographies of the included studies, was performed. between biofilms may explain part of the failures observed along PMP period. The impact that the Study selection subgingival instrumentation has over the amount Two independent reviewers (PDMA and AFS) and composition of the biofilm has been shown.12 nominated the articles that initially met the search However, not only the subgingival intervention but criteria, based on their titles. After agreement also the supragingival control modifies the quality on selected articles, the same 2 examiners read and quantity of the subgingival biofilm.13,14,15 Besides, the abstracts independently. Once the agreement evidences support the biofilm as the main source of was again accessed, the articles were elected for bacteria to the subgingival area.16 So, in theory, both full-text reading. The final inclusion of articles interventions, singly, would be able to maintain a was done after discussion and verbal agreement microbiota compatible with periodontal stability between the 2 examiners. A third examiner (SCG) and health along years. Taking this plausibility in reviewed any disagreement between the examiners mind, this systematic review aimed at investigating during all phases. how does the subgingival microbiota respond The selection of the articles was performed to the SPG in comparison with the SPG+SBG as according to: maintenance protocols. a. Type of study and patients: human randomized or non-randomized clinical Methodology trials (RCT/non-RCT) with at least 6 months of follow-up after periodontal treatment This systematic review was conducted in phase were included. The primary outcome accordance with the guidelines of the Preferred of the original/primary papers should be Reporting Items for Systematic and Meta-Analysis microbiological data or clinical outcomes (PRISMA) Statement17 and used the reference manager encompassing microbiological results as a Mendeley (version Desktop 1.16.1-OSX-Universal; secondary outcome. Studies were not included Elsevier Inc., New York, USA). Neither a protocol if: a) patients were not systemically healthy; nor a systematic review registration was considered. or b) patients received implant prosthesis, surgical regenerative therapies, or were not Focused question previously treated to periodontal disease. In periodontal patients submitted to PMP, is there b. Type of interventions during PMP: studies with a difference in the subgingival microbiological a PMP based on non-surgical interventions outcomes from the SPG regimen as compared to the were included. The experimental interventions SPG+SBG intervention? should be based on SPG or SPG+SBG interventions. When studies were based in Search strategy antibiotics and/or supragingival chemical Studies were identified by electronic databases control, data concerning control groups, i.e. (MEDLINE via PubMed, and EMBASE) searching for just mechanical intervention with or without studies published up to August 2016. No language placebo, were included in the analysis. restrictions were applied. The following MesH c. Type of outcomes: subgingival microbiological terms were used in different arrangements results were considered irrespective of the (Appendix 1-A; 1-B): randomized clinical trial; microbiological method used including both randomized controlled trial; clinical trial; longitudinal qualitative and/or quantitative analyses. 2 Braz. Oral Res. 2017;31:e33 Angst PDM, Stadler AF, Oppermann RV, Gomes SC. Quality assessment studies were sought and analyzed to complete Method of randomization, blinding of examiners, and/or clarify data from the included study. rate of patient losses during the follow-up, and the protocol and periodontal status information Statistical analysis were evaluated to access the quality of the studies Inter-examiner agreement for studies selection selected based on an adaptation of the Jadad scale.18,19 based on titles and abstracts was calculated using Each item was scored: 0: not shown or absent the Kappa coefficient. information; 1: incomplete or unclear information, As a consequence of the great discrepancy how or 2: complete/adequate information. The achievement results were presented by the authors, assessment of a sum score of at least 4 was necessary to the study of statistical heterogeneity or a meta-analysis could to be included (Appendix 2). A total score of 4 or not be conducted. 5 corresponded to an adequate quality, whereas a final score of 6 to 8 corresponded to a good quality. Results Data extraction Searching results Data were extracted considering: 1) the methodology The electronic searches resulted in 3,563 of the studies and 2) the microbiological finds. (MEDLINE) plus 879 (EMBASE) and the manual 1. Study methodology: in 19 titles. After extracting duplicate citations, a. Study design: type of study, period of 2,250 potential articles remained to be screened evaluation, experimental group included in (dated from 1968 on). From these, 148 after title and the analysis, and the set out baseline moment 39 after abstract analysis were considered to full-text of the PMP; evaluation. This evaluation resulted in the inclusion b. Sample: size, gender, age, smoking habit, and of 19 articles (Figure 1; Appendix 3). Kappa values initial periodontal diagnosis of the participants; for inter-examiner agreement were 0.71 and 0.79 for c. Quality: data obtained from the quality titles and abstract analyses, respectively. assessment and respective final score; Table 1 shows the results of the quality assessment d. Treatment phase intervention: interventions of the included studies. All studies presented, at least, employed before the PMP commencement;
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