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Efficacy of %2 Ibuprofen Subgingival Irrigation As an Adjunct to Non Journal of Advanced Periodontology & Implant Dentistry Research Article Efficacy of %2 ibuprofen subgingival irrigation as an adjunct to non-surgical therapy in the treatment of chronic periodontitis: A randomized controlled, split-mouth, clinical trial Amirhossein Farahmand1 • Ferena Sayar2* • Zohreh Omidali3 • Mahsa Soleimani1 • Bahareh Jafarzadeh Esfahani3 1Department of Periodontics, Faculty of Dentistry, Islamic Azad University, Tehran, Iran 2Department of Periodontics, Tehran Medical Sciences, Islamic Azad University, Tehran, Iran 3Dentist, Private Practice *Corresponding Author; E-mail: [email protected] Received: xx mm 2019; Accepted: xx mm 2019 J Adv Periodontal Implant Dent 2019;11(2):x-x| doi:10.15171/japid.2019.0xx This article is available from https://japid.tbzmed.ac.ir/ © 2019 The Authors. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecom- mons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Abstract Background. Pharmacological factors, such as ibuprofen, released topically in the periodontal pocket modulate the host response and enhance the influence of non-surgical periodontal treatment. Methods. In this double-blind, randomized, split-mouth, clinical trial, 38 outpatients with mild to moderate chronic perio- dontitis were enrolled by applying the simple random sampling method. They had at least one tooth with a periodontal pocket depth of >4 mm in each quadrant and had undergone phase I of periodontal treatment one week after scaling and root planing (SRP). The parameters of clinical periodontal evaluation, including probing pocket depth (PPD), clinical attachment level (CAL), plaque index (PI), and bleeding index (BI), were measured. In addition, two mandibular molar teeth in one quadrant were randomly nominated for subgingival irrigation with 0.5 mL of 2% ibuprofen or placebo mouthwash. The measurements were repeated after at least one week for three months. Results. Thirty-four individuals (18 women and 16 men), with an age range of 28‒36 years, were evaluated for three months. Moreover, periodontal clinical parameters were assessed within three months. There was a significant improvement in pocket depth (PD) and clinical attachment level (CAL) readings after 12 weeks in both groups (paired t-test). On comparing, the group with scaling and root planing (SRP) + ibuprofen showed more favorable results than the group with SRP + placebo (P<0.05). There were significant improvements in PI and BI in both groups; the differences between the two groups were significant (P<0.05). Conclusion. The mouthwashes containing ibuprofen might reduce the symptoms of periodontal disease and might be used as an adjunct in the healing process. Key words: Chronic periodontitis, ibuprofen, irrigation, non-surgical, periodontal therapy. 2 Farahmand et al. Introduction employment appears to be of particular interest. These products might result in a greater decrease in the hronic periodontitis is an infectious disease harmful systemic influences of non-selective NSAIDs C marked by periodontal pocket formation that re- in the long-term host modulation of periodontitis-sus- sults in the inflammation and destruction of periodon- 1 ceptible subjects (20). Furthermore, studies have tal tissues. It is well known that periodontal disease shown that prostaglandin production inhibitors, in- mainly progresses due to bacterial infection; however, cluding non-steroidal antiinflammatory drugs the initiation and progression of the disease can vary (NSAIDs), can influence this phase of bone loss in among objects in terms of genetic predisposition, sys- 21 2-4 periodontal disease. The current study aimed to temic status, and environmental effects. There is a evaluate the clinical effectiveness of subgingival irri- large body of studies showing that both surgical and gation with 2% ibuprofen as an adjunct to scaling and non-surgical periodontal treatments are effective root planing (SRP) in patients with chronic periodon- against periodontitis by eliminating pathogenic dental titis. plaque and calculus.5 Non-surgical periodontal treat- ment reduces pocket depth (PD) and increases clinical Methods attachment level (CAL) to some extent;6,7 however, it cannot fill the bony defect.8 In addition, some patients Study Protocol and Selection of Patients 9 do not respond to traditional periodontal treatment, This study was carried out as a single-center, exam- or exhibit a highly elevated susceptibility to periodon- iner-blinded, randomized, split-mouth clinical trial, 10 tal disease. Assessment of the mechanisms underly- with a two-arm, parallel-group design, in three ing these events has shown that the immune response months. This study was undertaken to assess the clin- of patients seems to play a critical role in the exten- ical application of a combination plus locally applied 11,12 sion and the manifestation of periodontal diseases. ibuprofen (2%) mouthwash (made in the Faculty of The host modulation treatment is to restore the bal- Pharmaceutical Sciences, Islamic Azad University, ance of pro-inflammatory or destructive mediators Tehran, Iran) in combination with SRP versus SRP + and antiinflammatory or protective mediators to that placebo mouthwash. The clinical measures of perio- seen in healthy patients. Host modulation treatment is dontal disease were evaluated in patients attending the a method believed to decrease tissue damage and Department of Periodontics, Faculty of Dentistry, Is- maintain or even restore inflammatory tissues by al- lamic Azad University, Tehran, Iran. Thirty-eight pa- 13 tering host response agents. However, non-steroidal tients of both genders, aged 28‒35 years, were se- antiinflammatory drugs (NSAIDs) are known as in- lected, who were diagnosed with mild to moderate hibitors of the formation of Prostanoids (including chronic periodontitis conforming to the 1999 Classi- prostaglandins and thromboxane), and this has been fication of Periodontal Diseases and Conditions with the source of much interest in the inhibitors of the host a probing depth >4 mm (Academy of Periodontology immune response to periodontal disease. Prostanoids in 1999).22 are produced during the activation of the cyclooxy- genase pathway to periodontal disease, which is asso- Inclusion Criteria ciated with tissue destruction and bone loss. Investi- The inclusion criteria consisted of a confirmed diag- gators suggest that selective NSAIDs (COX-2 inhibi- nosis of early moderate chronic periodontitis, at least tors) might reduce the bone loss associated with peri- two residual areas with a probing pocket depth (PPD) 14 odontitis; additionally, host modulation using vari- of >4 mm in two opposite quadrants, and CAL of ≥1‒ ous therapeutic agents targeting the manipulation of 2 mm, at least 20 remaining teeth with two teeth in the inflammatory pathway has been proposed as an every mandibular quadrant. The clinical periodontal adjunctive treatment with conventional periodontal parameters were determined and recorded at baseline 15-18 therapy. The latest survey determined that the use within seven days for 12 weeks in the selected teeth, of NSAIDs in combination with mechanical perio- at six locations in each tooth, using a periodontal dontal therapy improved bone maintenance in treating probe (Williams Probe, Hu-Friedy, USA) by two cal- 19 patients with periodontal diseases. Of all the various ibrated masked investigators (periodontists). Pocket combinations of these, such as flurbiprofen, ibuprofen depths were defined as the distance from the gingival is readily absorbed through the gingival tissues. margin to the bottom of the pocket, and CAL was de- Moreover, the development of local NSAID formula- fined as the distance from the cementoenamel junc- tions (e.g., gels, toothpaste, and rinses) with daily tion (CEJ) to the base of the pocket. PI was measured Subgingival Irrigation with 2% Ibuprofen Mouthwash 3 using a Silness & Löe index.23,24 BoP was evaluated study was calculated using “two-sample t-test sample through visual inspection 30 seconds after probing ac- size calculation” tab of MINITAB software, consider- cording to Carter & Barnes (score 0: no bleeding after ing α=0.05, β=0.05, a mean difference of 1.65, and probing; score 1: a single separate bleeding point be- pooled standard deviation=1.4. Finally, 17 subjects comes visible after probing).25 were necessary for each group. Exclusion Criteria Randomization and Blinding Patients with the following conditions were excluded: Randomization was carried out by one of the investi- known hypersensitivity to the components of the for- gators who did not have a role in the treatment of the mulation, those with systemic disease, pregnant and subjects. Eligible participants who proved their ongo- breastfeeding women, those undergoing orthodontic ing commitment to the study were block-randomized treatment, those with numerous dental bridges, those to treatment in a double-blinded manner, imple- taking antiinflammatory drugs, antibiotics, or immu- mented as block randomization with a 4:1 allocation. nosuppressive medicines in the latest three months, All the mouthwashes were placed in identical bottles those wearing a partial denture, those with numerous and labeled A or B. Each participant picked one sym- carious lesions, those habitually smoking, and those bol from a box to decide his/her sequence of the use with a history of
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