IAP Journal Jan 2011 Issue

Journal of the International
Academy of Periodontology
The ofcial journal of the International Academy of Periodontology

JIAP Oct 10 OFC.indd 1 23/09/2010 13:01:19
Volume 13 Number 1 January 2011
Published by
Stephen Hancocks Ltd
JIAP Jan 11 OFC.indd 1 22/12/2010 10:21:43
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Reference to an article: Shiloah, J. and Patters, M.R. Repopulation of Periodontal
Pockets by Microbial Pathogens in the Absence of Supportive Therapy. Journal
of Periodontology 1996; 67:130139.
Reference to a book: Schuster, G.S. Oral Microbiology and Infectious Diseases, 3rd ed.
Philadelphia: B. C. Decker, 1990; 516522.
Reference to a chapter in a book: Chesney, J., Patters, M.R. and Budreau-Patters, A.
Oral Infections. In Long, S., Prober, C. and Pickering, L. (Eds): Principles and
Practice of Pediatric Infectious Disease. New York. John Wiley and Sons, 1996.
Reference to a dissertation or thesis: James, A. On the Immune Response to GTR
Membranes in Periodontics. PhD, Liverpool, UK. 1994; 1525.
Reference to a report: Committee on Mercury Hazards in Dentistry. Code of
Practice for Dental Mercury Hygiene. London: Department of Health and
Social Security, 1979; Publication No. DHSS 79-F372.
Reference to an abstract: Patters, M.R., Shiloah, J., Dean, J.W., Bland, P. and
Toledo, G. The Consequence of Infection of Treated Periodontal Pockets
by Microbial Pathogens. Journal of Dental Research 1997; 76 (special issue),
111 (Abst).
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INFORMATION FOR AUTHORS
Journal
of the
International Academy of
Periodontology
Volume 13
Number 1
January 2011
ISSN 14662094
EDITORIAL BOARD
Mark R Patters
Editor
Memphis, TN, USA
Andrea B Patters
Associate Editor
Sultan Al Mubarak
Riyadh, Saudi Arabia
P Mark Bartold
Adelaide, SA, Australia
Michael Bral
New York, NY, USA
Nadine Brodala
Chapel Hill, NC, USA
Cai-Fang Cao
Beijing, Peoples Republic of China
Chong-Pyoung Chung
Seoul, Korea
Daniel Etienne
Paris, France
Erhan Firatli
Istanbul, Turkey
Kohji Hasegawa
Tokyo, Japan
Vincent J Iacono
Stony Brook, NY, USA
Isao Ishikawa
Tokyo, Japan
Georges Krygier
Paris, France
Yoji Murayama
Okayama, Japan
Hamdy Nassar
Cairo, Egypt
Angela R C Pack
Dunedin, New Zealand
David Paquette
Chapel Hill, NC, USA
Stephen Polins
Boston, MA, USA
Rok Schara
Ljubljana, Slovenia
Lior Shapira
Jerusalem, Israel
Uros Skaleric
Ljubljana, Slovenia
Aubrey Soskolne
Jerusalem, Israel
Thomas E Van Dyke
Boston, MA, USA
The Effect of Different Interdental Cleaning Devices on Gingival Bleeding
Nanning A. M. Rosema, Nienke L. Hennequin-Hoenderdos, Claire E. Berchier,
Dagmar E. Slot, Deborah M. Lyle and Godefridus A. van der Weijden 2
Additive or Synergistic Antimicrobial Effects of Amoxicillin and
Metronidazole on Whole Plaque Samples: A Preliminary Report
Clemens Walter, Eva M. Kulik, Roland Weiger, Nicola U. Zitzmann and
Tuomas Waltimo

11
Clinical and Microbiological Comparison of Three Non-surgical
Protocols for the Initial Treatment of Chronic Periodontitis
Carlos Serrano, Nidia Torres, Angela Bejarano, Marcela Caviedes and
Mara Eugenia Castellanos 17
13th International Biennial Congress - Registration Form 27
The Journal of the International Academy of Periodontology is the official journal of the International Academy of
Periodontology and is published quarterly (January, April, July and October) by Stephen Hancocks Ltd in association with Dennis
Barber Ltd.
Manuscripts, prepared in accordance with the Information for Authors should be submitted to the Editor, Dr. Mark R. Patters, University
of Tennessee, Department of Periodontology, 875 Union Avenue, Memphis, TN 38163, USA. Electronic submissions will be accepted and
should be sent to jiap@utmem.edu. Instructions to Authors are available at: http://www.perioiap.org/publications.htm#JOURNAL
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consequences of any such inaccurate or misleading opinion or statement.
2011 International Academy of Periodontology.
All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any
means, electronic, mechanical, photocopying, or otherwise, without permission of the Academy.
Produced in Great Britain by Dennis Barber Limited, Lowestoft, Suffolk
JIAP Jan 11 Contents pp1.indd 97 23/12/2010 10:18:46
International Academy of Periodontology
Journal of the International Academy of Periodontology 2011 13/1: 210
Correspondence to: N.A.M. Rosema. Department of Period-
ontology, Academic Centre for Dentistry Amsterdam (ACTA),
University of Amsterdam and VU University Amsterdam, Gus-
tav Mahlerlaan 3004 1081 LA Amsterdam, The Netherlands.
E-mail: M.Rosema@acta.nl
The Effect of Different Interdental Cleaning
Devices on Gingival Bleeding
Nanning A. M. Rosema
1
, Nienke L. Hennequin-Hoenderdos
1
,
Claire E. Berchier
1
, Dagmar E. Slot
1
, Deborah M. Lyle
2
and
Godefridus A. van der Weijden
1
1
Department of Periodontology, Academic Centre for Dentistry
Amsterdam ACTA, University of Amsterdam and VU University
Amsterdam,The Netherlands, and
2
Water Pik Inc, Fort Collins, CO, USA
Abstract
Objective: To compare the effectiveness of an oral irrigator (OI) with a prototype jet
tip or a standard jet tip to foss as adjunct to daily toothbrushing on gingival bleeding.
Methods: In this single masked, 3-group parallel, 4-week home use experiment, 108
subjects were randomly assigned to one of three groups: 1) OI with a prototype jet tip;
2) OI with a standard jet tip; 3) waxed dental foss. All groups used their assigned prod-
uct once a day as adjunct to twice daily toothbrushing for two minutes with a standard
ADA reference toothbrush. Professional instructions were given by a dental hygienist in
OI use or foss use according to written instructions. All subjects also received a tooth-
brush instruction leafet (Bass technique). Subjects were assessed for both bleeding and
plaque at baseline and after two weeks and four weeks and were instructed to brush
their teeth approximately 2 to 3 hours prior to their assessment. Results: With respect to
mean bleeding scores the ANCOVA analysis with baseline as covariate and week 4 as
dependent variable showed a signifcant difference between groups in favor of both the
oral irrigator groups. For plaque, however, no signifcant difference among groups was
observed. Conclusion: When combined with manual toothbrushing the daily use of an
oral irrigator, either with prototype or standard jet tip, is signifcantly more effective in
reducing gingival bleeding scores than is the use of dental foss, as determined within
the limits of this 4-week study design.
Key words: Floss, dental water jet, oral irrigator, water fosser, gingivitis, bleeding,
plaque, toothbrush
Introduction
Bioflms are 3-dimensional arrangements of bacteria
that are loosely or more frmly adherent to teeth and
tissue (Costerton et al., 1994). Bioflms consist of micro-
colonies of bacteria embedded in slimy matrices and are
self-suffcient, dynamic communities that can survive in
hostile environments (Marsh and Bradshaw, 1995) The
regular removal of dental plaque bioflm, which contains
the bacteria responsible for caries formation and for
the etiology of gingivitis and periodontitis, is the well-
accepted conditio sine qua non of dental health (Gorur et al.,
2009). Mechanical removal is considered the most effec-
tive method to control the growth of the oral bioflm. The
most common device used for mechanical plaque control
is either a manual or power toothbrush. As toothbrush
effcacy is limited to the surfaces of the teeth it can access
(facial, lingual, and occlusal), another device is needed to
clean the interdental area and the proximal surfaces of
the teeth and surrounding gingivae. Other factors that
affect the effcacy of mechanical plaque bioflm removal
include brushing frequency, brushing time, toothbrush
design, and brushing technique (Jepsen et al., 1998; Van
der Weijden et al., 1993).
For most people, however, total plaque bioflm
removal is not a realistic goal. It is diffcult for patients
to effectively remove or disrupt the bioflm from all
surfaces of the teeth on a daily basis (Douglass et al.,
1993; Brown et al., 1993). On average, people reduce
their plaque scores by approximately 50% by brushing
(Jepsen et al., 1998). Therefore, compliance with instruc-
tions is a major consideration when recommending any
self-care device. To be truly patient-centered, practitio-
ners must shift to recommending available tools that,
besides having demonstrated effcacy in reducing infam-
mation based on scientifc evidence, are also preferred
by patients (Slot et al., 2008).
JIAP 10-005 Rosema.indd 2 04/01/2011 11:37:43
The Effect of Different Interdental Cleaning Devices on Gingival Bleeding 3
A dental water jet or water fosser or oral irrigator
(OI) is an electric device that delivers a pulsating fuid
via controlled pressure which is aimed at the removal
of interdental and subgingival plaque bioflm on tooth
surfaces to reduce infammation as a supplement to
toothbrushing (Lobene, 1969; Drisko et al., 1987; Cobb et
al., 1988; Flemmig et al., 1990; Chaves et al., 1994; Flem-
mig et al.,1995; Barnes et al., 2005; Gorur et al., 2009).
The OI was introduced to the dental profession in 1962
and has been studied extensively for the past decades.
Clinical studies demonstrate that an OI is safe and can
signifcantly reduce bleeding and gingivitis in a variety
of cohorts (Lobene et al., 1969; Flemmig et al., 1990;
Brownstein et al., 1990; Burch et al., 1994; Newman et
al., 1994; Flemmig et al., 1995; Felo et al., 1997; Barnes
et al., 2005; Sharma et al., 2008). However, erythrosine-
based plaque indices have yielded equivocal data. Some
studies have shown a reduction in plaque indices with
the use of the OI compared to toothbrushing alone
(Burch et al., 1994; Felo et al., 1997; Cutler et al., 2000;
Al Mubarak et al., 2002; Sharma et al., 2008), while other
studies showed no signifcant differences (Ciancio et al,
1989; Brownstein et al., 1990; Walsh et al., 1992; Chaves
et al., 1994; Fine et al., 1994).
The OI is likely to provide a particular beneft in
terms of gingival health to a large part of the general
public that does not clean the interproximal spaces
on a regular basis (Research, Science and Therapy
Committee, 2005). In 2001 the American Academy of
Periodontology stated, Among individuals who do not
perform excellent oral hygiene, supragingival irrigation
with or without medicaments is capable of reducing
gingival infammation beyond that normally achieved
by toothbrushing alone. This effect is likely due to the
fushing out of subgingival bacteria (Research, Science
and Therapy Committee, 2001). In a 2005 position
paper, the American Academy of Periodontology stated
that supragingival lavage can assist individuals with
gingivitis or poor oral hygiene. The greatest beneft is
seen in patients who perform inadequate interproximal
cleansing. Patients report that the OI facilitates the
removal of food debris in posterior areas, especially
in cases of fxed bridges or orthodontic appliances,
when the proper use of interdental cleaning devices is
diffcult (Research, Science and Therapy Committee,
2005). However, anecdotal discussions and commentary
continue concerning the appropriate use and effcacy
of this instrument. OI devices can be used with water
but also with antimicrobial agents (Flemmig et al., 1990,
Brownstein et al., 1990, Jolkovsky et al., 1990; Newman
et al., 1994, Fine et al., 1994; Chaves et al., 1994; Flemmig
et al., 1995; Felo et al., 1997).
The objective of the present study was to test the
adjunctive effect to toothbrushing of an OI with either
a prototype jet tip or a standard tip in the potential to
improve gingival health over a 4-week period. This pro-
totype tip, which is confgured with flaments, may help
the user guide the tip along the gingival margin and the
interproximal area. Both OI tips were compared to the
use of dental foss. These treatments were combined
with the use of a regular fat trimmed manual toothbrush
together with a standard dentifrice.
Materials and methods
Study population
One hundred seventy-two subjects (non-dental students)
from different universities and colleges in and around
Amsterdam responded to an e-mail advertisement and
reported for a screening appointment. The volunteers
were informed about the study, frst in a recruitment
letter and secondly at the screening. Participation was
not limited by race or gender. Subjects received a written
explanation of the background of the study, its objec-
tives and their involvement. Before screening for their
suitability they were all requested to give their written
informed consent. Subjects were required to fulfll the
following criteria: 18 years of age, a minimum of
fve evaluable teeth in each quadrant (with no partial
dentures, orthodontic banding or wires); moderate
gingivitis (50% bleeding on marginal probing, Galgut et
al., 1998), an absence of oral lesions and/or periodontal
pockets > 5 mm and/or generalized recession, and the
absence of pregnancy and systemic diseases such as
AIDS, cirrhosis, diabetes, any adverse medical history
or long-term medication, or any physical condition that
limits manual dexterity. All subjects received oral and
written information about the products and purpose
of the study. One hundred eight subjects met the in-
clusion criteria and were enrolled into the study, which
was conducted in accordance to the ethical principles
that have their origin in the Declaration of Helsinki and
was consistent with Good Clinical Practice guidelines.
Medical Ethics Committee approval was obtained prior
to the start of the study (MEC 09/198 #09.17.1322).
All assessments took place at the Department of Peri-
odontology at ACTA, Amsterdam, The Netherlands in
September and October, 2009.
Study products
Three different interdental products were tested in this
study, one product per group, with 36 subjects enrolled
in each group. All subjects received a standard tooth-
brush (Oral-B Indicator 35, Procter & Gamble, Cincin-
nati, OH, USA, Figure 1) and standard fuoride dentifrice
(Everclean, HEMA, Amsterdam, The Netherlands).
In addition, subjects were randomized (see below for
details) into one of three groups for assignment of an
interdental cleaning device:
JIAP 10-005 Rosema.indd 3 04/01/2011 11:37:43
4 Journal of the International Academy of Periodontology (2011) 13/1
Group 1 (OIP): OI (DWJ-Waterpik Ultra Water
Flosser, Fort Collins, CO, USA) with a prototype jet tip
(Figure 2, test group).
Group 2 (OIS): OI (DWJ-Waterpik Ultra Water
Flosser, Fort Collins, CO, USA) with a standard jet tip
(Figure 3, benchmark control group, Husseini et al., 2008).
Group 3 (DF): standard waxed foss (Johnson &
Johnson, New Brunswick, NJ, USA) (Figure 4, control
group).
Clinical assessment
Clinical parameters were assessed at baseline (S1), week
2 (S2), and week 4 (S3). First gingivitis and then plaque
was scored. All gingivitis assessments were carried out
by the same trained examiner (NLH). All plaque assess-
ments were carried out by a second trained examiner
(CEB). All examinations were carried out under the
same conditions. All teeth were examined for both
indices at six sites per tooth (disto-buccal, mid-buccal,
mesio-buccal, disto-lingual, mid-lingual, mesio-lingual)
except for 3
rd
molars.
Criteria
Gingivitis was assessed as the primary outcome using
the bleeding on marginal probing index (BOMP) as
described by Van der Weijden et al. (1994a, 1994b) and
Lie et al. (1998). In short, the gingival margin is probed
at an angle of approximately 60 to the longitudinal axis
of the tooth and the absence or presence of bleeding
is scored within 30 seconds of probing on a scale 0 - 2
(0 = no bleeding, 1 = pinprick bleeding, 2 = excessive
bleeding).
Plaque was assessed as a secondary outcome using
the Turesky (1970) modifcation of the Quigley & Hein
(1962) plaque index (TQHPI) as described in detail by
Figure 1. Toothbrush - Oral-B indicator 35
Figure 2. OIP - oral irrigator with prototype tip
Figure 3. OIS - oral irrigator with standard tip
Figure 4. DF - standard waxed dental foss
JIAP 10-005 Rosema.indd 4 04/01/2011 11:37:47
Figure 5. Flowchart
Flowchart
Screening
Baseline (S1)
2 Weeks (S2)
4 Weeks (S3)
Statistical
Analyses
(ITT)
Screening
172 subjects
Excluded
64 subjects
Total: 108 subjects
Group 1: 36 subjects
BOMP & TQHPI
Professional instruction
Total: 106 subjects
BOMP & TQHPI
Drop-out
2 subjects
Drop-out
2 subjects
Total: 104 subjects
BOMP & TQHPI
Total: 104 subjects
Paraskevas et al. (2007). Briefy, the teeth were dyed us-
ing a new cotton swab with fresh disclosing solution
(Mira-2-Ton
; Hager & Werken GmbH & Co. KG.

Duisburg, Germany) for each quadrant in order to dis-
close the plaque. Subsequently, the absence or presence
of plaque was recorded on a 6-point scale (0-5, 0 = no
plaque, 5 = plaque covering more than two-thirds of
the tooth surface).
Study design
This study was designed as single masked, 3-group paral-
lel, 4-week home use experiment. After meeting the inclu-
sion criteria, completion of a medical questionnaire and
informed consent, subjects returned to the clinic for their
frst (baseline) assessment (S1) for both clinical param-
eters (bleeding on marginal probing and plaque). At the
start of the experiment all subjects received a unique trial
number. Subjects were randomly assigned to one of three
groups according to a randomization list (www.random.
org). The allocation of products was carried out by the
study coordinator, who was responsible for allocation
concealment. All products were distributed in such a way
that blindness of the examiners was assured. At the last
visit (S3) the study coordinator assured blindness of the
JIAP 10-005 Rosema.indd 5 04/01/2011 11:37:48
examiners by collecting the study products in a separate
room from where the clinical examinations took place.
Subjects were also instructed not to mention anything
to the examiners that could lead to allocation disclosure.
During the 4-week experimental phase OIS and
OIP subjects used the OI once a day in the evening
with lukewarm tap water and were instructed to fnish
one container of 500 ml at each occasion. Subjects in
the control group (DF) used standard waxed dental
foss once a day in the evening. At the baseline visit
(S1), immediately following the baseline assessment,
subjects used their allocated product for the frst time.
The study coordinator (NAMR) was present to provide
detailed verbal instruction, a demonstration to ensure
correct use, and aid with further personal instruction
when necessary. Subjects in both OI groups were
instructed to use the OI according to the instruction
leafet provided by the manufacturer. Subjects in the DF
group were instructed to use their product according
to the description of Van der Weijden et al. (2008). All
subjects in each group were instructed to brush twice a
day in their normal manner, once in the morning after
breakfast and once in the evening. In the evening they
subsequently used their assigned product (OI or DF).
All participants were instructed to refrain from using
any other oral hygiene product or device such as tooth-
picks, interdental brushes, mouthrinses, etc., during the
study period. To check for compliance, subjects were
asked to register the time of use of the products onto
a calendar record chart.
After two weeks (S2), subjects returned to the clinic
for the second clinical assessment for both gingivitis
and plaque. After four weeks (S3), subjects visited the
clinic for their fnal assessment for both parameters.
Subjects were asked to return all products provided for
this study as well as the calendar record chart. On each
occasion subjects were instructed to brush between 2
and 3 hours prior to their appointments to avoid the
risk of increased bleeding on probing as a result of
toothbrushing (Abbas et al., 1990). The day prior to each
appointment all subjects received an SMS-message as a
reminder with the following text: Remember that you have
an appointment at ACTA! Note that you need to brush your
teeth 2-3 hours prior to your visit. See you tomorrow! ACTA.
After the fnal assessment habitual oral hygiene proce-
dures were resumed.
Data analyses
The unit of analysis was the subject and collected data
were analyzed as intention to treat. The bleeding scores
were used as the main response variable (Galgut et al.,
1998) and plaque scores as secondary response variable.
A priori calculations with an alpha of 0.05, a difference
of 0.0883 (between groups) of the bleeding index with
80% power, based on a pooled SD of 0.13 as derived
from previous studies supported a sample size of 105.
An analysis of covariance (ANCOVA) with S1 as cov-
ariate and S3 as dependent variable was performed to
compare groups over time (Heynderickx et al., 2005).
Analyses comparing differences between the test and
control groups at each time point were performed
using non-parametric tests. Explorative analyses were
performed to investigate the origin of the overall differ-
ences. P values of < 0.05 were accepted as statistically
signifcant.
Results
Of 108 subjects who started the trial, four subjects did
not complete the protocol. One chose not to continue
the trial for personal reasons. Another left the country
and moved abroad. Two did not attend the second visit
because of scheduling conficts. This resulted in a study
population of 104 subjects providing evaluable data
(Figure 5). The study population data on demographics
and pre-study foss habits are presented in Table 1. No
adverse events were reported by any of the subjects who
participated in this study.
Results for bleeding on probing are presented in Table
2. The overall ANCOVA analysis showed a statistically
signifcant difference between the three groups (p =
0.007). Mean overall reductions after four weeks of use
(S1 to S3) were 0.15 for the OIP group, 0.17 for the OIS
group, and 0.02 for the DF group. The mean bleeding
scores of the three groups did not differ signifcantly at
baseline. At session 2 the scores decreased for all three
groups. Post testing showed that both the OI groups
provided signifcantly lower bleeding scores as compared
to the DF group. At session 3 a statistically signifcant
difference could be detected among the three groups.
Post testing showed that again both the OI groups had
signifcantly lower bleeding scores as compared to the
DF group. The 95% confdence interval of the differ-
ence compared to the DF group at S3 was -0.27 -0.04
for the OIP group and -0.28 -0.05 for the OIS group.
Results for plaque index are presented in Table 3.
With regard to the plaque scores the overall ANCOVA
analysis showed no statistically signifcant differences
among the three groups (p = 0.126). Mean overall re-
ductions after four weeks of use (S1 to S3) were -0.09
for the OIP group, 0.06 for the OIS group, and 0.01
for the DF group.
Discussion
Effective brushing remains the most obvious way of
maintaining low levels of plaque and good gingival
health. Gingivitis is known to be associated with the
onset of periodontitis, and although the relationship be-
tween these two conditions may not be fully understood,
the importance of maintaining good gingival health and
JIAP 10-005 Rosema.indd 6 04/01/2011 11:37:48
this with traditional dental foss (Asadoorian, 2006).
Thus, compliance with foss is low (Warren and Chater,
1996), and various adjuncts for interdental cleaning have
been studied. Dental foss, toothpicks, woodsticks and
interdental brushes have all been recommended for
this purpose.
The present study focussed on the ability to reduce
gingival infammation in a population of young individu-
als with moderate gingivitis using an OI. The OI works
through the direct application of a pulsed stream of
water or other solution. A study duration of four weeks
was chosen to monitor the changes in the bleeding index,
which meets the ADA guidelines on OIs for studies as-
sessing the effects of adjunctive therapies on reduction
of gingivitis (ADA, 2008). Studies of longer duration
will more clearly demonstrate the clinical beneft that
subjects will obtain from this product.
The effcacy of use of foss on the bleeding index
was considered inconclusive in a systematic review by
Berchier et al. (2008). The results of the present study are
Table 1. Demographic data and pre-study fossing habits of the study population.
OIP, oral irrigation device with prototype jet tip; OIS, oral irrigation device with standard jet
tip; DF, dental foss
Total OIP OIS DF
N 104 34 34 36
Female 74 24 27 23
Male 30 10 7 13
Age [range] (SD) 21.8 [18-36] 21.9 (3.2) 21.1 (2.3) 22.4 (3.1)
Daily foss users 6 2 1 3
Weekly foss users 16 7 4 5
Monthly foss users 20 9 7 4
Seldom/never foss users 62 16 22 24
Table 2. Mean bleeding index (BOMP) and mean % bleeding scores for all groups at all sessions.
Standard deviation in parentheses. Univariate analyses of covariance with session 1 as covariate and session 3 as depen-
dent variable. (p = 0.007). *Statistically signifcant difference compared to DF group, p < 0.05 (Mann-Whitney).
Statisti-
cally signifcant difference compared to DF group, p = 0.020 (Mann-Whitney). OIP, oral irrigation device with prototype
jet tip; OIS, oral irrigation device with standard jet tip; DF, dental foss
N Session 1 Session 2 Session 3 Relative Reduction Relative Reduction
S1 S2 S1 S3
OIP - index 34 0.82 (0.25) 0.65 (0.24) 0.67 (0.26)
% 46 % 37 % 39 % 20 % 15 %
OIS index 34 0.83 (0.23) 0.61 (0.27)* 0.66 (0.26)*
% 46 % 34 % 38 % 26 % 17 %
DF - index 36 0.86 (0.26) 0.74 (0.26) 0.84 (0.30)

% 47 % 41 % 47 % 13 % 0 %
p - value
(Kruskal Wallis)
0.579 0.084 0.016
Univariate analyses of covariance with session 1 as covariate
and session 3 as dependent variable. (p = 0.126). OIP, oral
irrigation device with prototype jet tip; OIS, oral irrigation
device with standard jet tip; DF, dental foss
Table 3. Mean Quigley & Hein plaque scores standard
deviation for all groups at all sessions.
N Session 1 Session 2 Session 3
OIP 34 1.64 0.43 1.61 0.34 1.73 0.37
OIS 34 1.79 0.34 1.74 0.29 1.73 0.28
DF 36 1.60 0.26 1.51 0.27 1.59 0.27
preventing periodontitis is well recognised (Van Dyke et
al., 1999). As the interproximal area is known as where
the onset of gingival infammation is likely to occur,
the reason for interproximal plaque control seems clear.
Although it is universally recognized that interproximal
cleansing is essential for controlling periodontal disease
(Le, 1979), many people have diffculty accomplishing
JIAP 10-005 Rosema.indd 7 04/01/2011 11:37:48
in support of this statement. In contrast, in the present
study both OI groups did show statistically signifcant
improvements after four weeks. At the end of the study
both OI groups show a signifcant 15 - 17% reduction
of the bleeding index as compared to baseline. For the
DF group this difference was not observed. Compari-
sons among groups showed a signifcant difference at
four weeks between the DF group and both OI groups.
The absolute difference of 8% and 9% at four weeks
for both OI groups as compared to the foss group re-
veals a relative effect of 17% (OIP) and 19% (OIS). In
consideration of the ADA guidelines for oral irrigators,
the results of the present study do not reach the lower
limit of superiority of 20% as estimated proportionate
reduction related to clinical relevance as compared to
standard oral hygiene procedures (ADA, 2008). How-
ever, the ADA also has guidelines on adjunctive dental
therapies (ADA, 1997). In those guidelines a lower limit
of 15% is applied. The study outcomes of the present
study do comply with this guideline, indicating a poten-
tial benefcial effect for the OI.
With respect to plaque, the DF group started with a
markedly lower score as compared to both OI groups.
All subjects were instructed to brush 2-3 hours prior
to examination, to reduce the risk of greater bleeding
tendency (Abbas et al., 1990). As the difference in PI
scores was consistent throughout the study and was not
refected in bleeding index scores, it seems that subjects
who were randomly allocated to the foss group coin-
cidently performed better instant plaque removal by
brushing at visit days. In a study carried out by Galgut
et al. (2000) the effect of unevenly distributed baseline
data is discussed and it was concluded that this might
not infuence the results and the conclusions drawn.
Historically, plaque reductions are considered a pre-
requisite for an oral hygiene device to be considered
effective (Le et al., 1965). A recent systematic review
(Husseini et al., 2008) reported no statistically signifcant
reduction in plaque when the OI was used as an adjunct
to toothbrushing when compared to toothbrushing only.
Despite a lack of effect on plaque index, the studies that
were included in this review did fnd a signifcant effect
on bleeding and gingival indices. The mechanisms of
actions underlying these clinical changes for the bleeding
index in the absence of a clear effect on plaque are not
understood, although different hypotheses have been
put forward (Husseini et al., 2008). One of the hypoth-
eses is that supragingival irrigation alters the popula-
tion of key pathogens, reducing gingival infammation
(Flemming et al., 1995). Another hypothesis is that the
water-pulsation may alter the specifc host-microbial
interaction in the subgingival environment (Chaves et
al., 1994). There is also the possibility that the benefcial
action of an OI is at least partly because of the removal
of loosely adherent soft deposits interfering with plaque
maturation and stimulation of the immune response
(Frascella et al., 2000). Other explanations could be a
mechanical stimulation of the gingiva or a combina-
tion of the above-mentioned factors (Frascella et al.,
2000; Flemmig et al., 1990). Furthermore, irrigation may
reduce the thickness of the plaque, which may not be
easily detectable using 2-dimensional scoring systems
(Jolkovsky et al., 1990).
The absence of an effect for DF at four weeks may
also seem surprising. A transient effect of 6% BI re-
duction was observed at two weeks. However, a recent
systematic review supports this fnding that dental foss
has no signifcant effect on plaque or bleeding indices
(Berchier et al., 2008). The small effect observed at two
weeks is most likely the result of a novelty or Hawthorne
effect. The Hawthorne effect is a reaction of subjects to
the realization they are in a study and are being observed
(Adair et al., 1984). The novelty effect and Hawthorne
effect can be considered as certain placebo effects. The
impact of a placebo effect should not be underestimated
(Finniss et al., 2010). In a study by Feil et al. (2002), the
Hawthorne effect was intentionally used and shown to
improve oral health. The novelty effect is something
that could have infuenced all groups within this model.
Subjects were pre-selected on having no experience
with an OI, whereas only six out of the 104 were regular
fossers (Table 1). The rebound that is observed from
the 2-week to the 4-week follow-up is, however, most
evident in the foss users. With respect to the Hawthorne
effect, this is probably not only present in the DF group
but also in both OI groups, as subjects were selected on
having a bleeding index of > 50%. However at session
1 the bleeding index was already reduced to 46-47%
for all three groups. This indicates that subjects already
acted as if they were entered into the protocol before
the frst assessment of the primary response variable.
The results of the present study add to the existing
data and clearly show a reduction in infammation from
using an OI. Interestingly, the reduction in bleeding
could not be linked to plaque removal. This is similar
to data presented by Flemmig et al. (1990) showing no
change in plaque scores for either the brushing group
or the brushing and irrigation group from baseline to 6
months, but a signifcant difference in bleeding on prob-
ing and gingival index scores in favor of the irrigation
group. Likewise, Flemmig et al. (1995) reported that the
water irrigation group was signifcantly better at reducing
bleeding on probing and gingival index scores compared
to the regular oral hygiene group at six months. Also
in this study there were no statistically signifcant dif-
ferences detected in plaque scores among the groups.
Chaves et al. (1994) found similar reductions in plaque
scores for water irrigation compared to toothbrush-
ing alone, and a signifcant difference for bleeding on
probing in favor of the irrigation group at six months.
JIAP 10-005 Rosema.indd 8 04/01/2011 11:37:48
These studies support the present data in fnding no
correlation between reduction of plaque bioflm and
infammation in 3-6 months.
Conclusion
There is a long-standing, well-documented body of
evidence supporting the use of an oral irrigator. An oral
irrigator is at least as effective as dental foss for reducing
gingival bleeding and gingivitis. When combined with
manual toothbrushing the use of an oral irrigator, either
with a prototype or standard jet tip, is signifcantly more
effective in reducing gingival bleeding scores as com-
pared to the use of dental foss, as determined within
the limits of this 4-week study design.
Acknowledgment
The study was performed in commission of ACTA
Research BV.
Waterpik Inc, Fort Collins, CO, USA initiated the
study project and provided study products. ACTA
Research BV received fnancial support for their com-
mitment to appoint this project to the Department of
Periodontology of ACTA.
D.M. Lyle is the director of professional and clini-
cal affairs for Water Pik, Inc. The authors employed by
ACTA declare that they have no confict of interest.
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Correspondence to: Prof. Dr. Nicola U. Zitzmann, Depart-
ment of Periodontology, Endodontology and Cariology,
School of Dentistry, University Basel, Hebelstrasse 3, CH-
4056 Basel, Switzerland. Email: n.zitzmann@unibas.ch
Additive or Synergistic Antimicrobial Effects
of Amoxicillin and Metronidazole on Whole
Plaque Samples: A Preliminary Report
Clemens Walter
1,2
, Eva M. Kulik
3
, Roland Weiger
1
, Nicola U.
Zitzmann
1
and Tuomas Waltimo
3
1
Department of Periodontology, Endodontology and Cariology,
School of Dentistry, University Basel, Switzerland;
2
Department of
Oral Surgery, School of Dentistry, University of Birmingham, United
Kingdom;
3
Institute for Preventive Dentistry and Oral Microbiology,
School of Dentistry, University Basel, Switzerland
Abstract
Objective: In vitro data on the susceptibility of oral bacteria to the combination of met-
ronidazole and amoxicillin is limited. The aim of this preliminary study was to determine
the susceptibility of whole subgingival plaque samples to amoxicillin and metronidazole
and to their combination. Methods: Prior to any treatment procedures subgingival
plaque samples from patients with severe generalized periodontitis were taken. Appro-
priate dilutions were plated on Columbia blood agar supplemented with the following
agents: 3 g/mL amoxicillin, 8 g/mL amoxicillin, 8 g/mL metronidazole, 16 g/mL
metronidazole, 3 g/mL amoxicillin plus 8 g/mL metronidazole or 8 g/mL amoxicil-
lin plus 16 g/mL metronidazole. All plates were incubated anaerobically at 36C for
14 days and the colony forming units (CFU) were determined. Results: Both applied
metronidazole concentrations were able to decrease the CFU counts by approximately
one order of magnitude in a log10 scale. Amoxicillin 3 g/mL revealed a reduction of
2.4 log10 CFU, whereas 50% of the samples did not grow on the plates supplemented
with 8 g/mL of amoxicillin. There was no anaerobic bacterial growth on agar plates
supplemented with the combination of amoxicillin and metronidazole even at the lower
antibiotic concentrations. Conclusion: Susceptibility screening of subgingival samples to
metronidazole and amoxicillin and to their combination seems to offer a rational basis
for the selection of adjunctive antibiotic therapy
Key words: Antibiotics, synergistic effect, aggressive periodontitis, metronidazole,
amoxicillin
Introduction
Periodontal diseases are multifactorial bioflm-associated
infections. A distinct differentiation between aggressive
and chronic forms is diffcult

(Meyer et al., 2004), even
on the basis of microbiological fndings (Mombelli et al.,
2002; Ximenez-Fyvie et al., 2006; Schacher et al., 2007).
Hence, the diagnosis of aggressive periodontitis is
primarily based on clinical and radiological character-
istics, on patients age, and on fndings derived during
clinical follow-up. Due to the infection-induced nature
of periodontal diseases, antimicrobial therapies based
on microbiological examinations may improve the treat-
ment outcome of advanced and/or aggressive forms
of periodontitis.
First attempts to control periodontal diseases with
the adjunctive use of antibiotics included systemic ad-
ministration of tetracyclines, amoxicillin with or without
clavulanic acid, clindamycin and metronidazole (Listgar-
ten et al., 1978; Lekovic et al., 1983; Gordon et al., 1985;
Magnusson et al., 1989). Another adjunctive treatment
approach was topical administration of various antibiot-
ics or antiseptics (Lindhe et al., 1979; Needleman and
Watts, 1989; Stabholz et al., 2000). Two decades ago,
the combination of metronidazole and amoxicillin - so
called van Winkelhoff-Cocktail - was introduced as
an adjunctive systemic therapy for periodontitis treat-
ment (Van Winkelhoff et al., 1989). This regimen was
specifcally designed for treatment of diseases associated
with Aggregatibacter (Actinobaccillus) actinomycetemcomitans,
for which a synergistic in vitro effect between the two
substances or their metabolites has been reported
JIAP 10-004 Zitzmann.indd 11 04/01/2011 11:39:02
(Pavicic et al., 1994a; Pavicic et al., 1994b). Clinical stud-
ies on aggressive forms of periodontitis have revealed
improved outcomes within observation periods up to
fve years, provided that the adjunctive treatment with
the combination of amoxicillin and metronidazole was
strictly combined with mechanical bioflm removal
(Buchmann et al., 2002; Guerrero et al., 2005; Kaner et al.,
2007a; Kaner et al., 2007b). Moreover, improved clinical
advantages of this regimen were found in a placebo-
controlled study comparing the antibiotic combination
to the agents alone, again as adjunctive to mechanical,
non-surgical periodontal treatment (Rooney et al., 2002).

In this report, the treatment outcomes of subjects with
advanced chronic periodontal disease were independent
from the initial microbiological fndings. Recently, this
strategy of combining amoxicillin and metronidazole
was used for the treatment of generalized aggressive
periodontitis without targeting against specifc micro-
organisms (Guerrero et al., 2005).
Whenever antibiotics are administrated as an adjunc-
tive periodontal treatment, existing or possibly develop-
ing resistance of the associated microfora should be
carefully considered. In vitro fndings have suggested that
there are remarkable differences in resistance profles of
certain oral bacterial species (Van Winkelhoff et al., 2005;
Lakhssassi et al., 2005). Recent fndings in microbiologi-
cal susceptibility testing have indicated the rationale of
the examination of mixed microbial cultures instead of,
or in addition to, the individual disease-associated strains
(Karbach et al., 2007). Such in vitro data about bacterial
susceptibility to the combination of amoxicillin and
metronidazole is hitherto scarce.
The aim of the present preliminary study was to
determine the susceptibility of whole subgingival plaque
samples to amoxicillin and metronidazole and to their
combination.
Materials and methods
Patients and sampling
Four generally healthy patients with severe generalized
chronic or aggressive periodontitis were recruited from
the pool of patients from the Department of Period-
ontology, Endodontology and Cariology at the School
of Dental Medicine, University of Basel, Switzerland.
Diagnosis was based on clinical and radiographic fnd-
ings, related to age and the severity of destruction (Table
1, Figure 1a-b, Armitage, 1999). Clinical measurements
of probing pocket depth and attachment level were
performed with the probe PCPUNC-15 (Hu-Friedy,
Chicago, IL, USA). All recruited patients (one female
and three males with a mean age of 40.8 years) were cur-
rent or former heavy smokers and had neither received
any earlier periodontal treatment nor systemic or topical
antibiotics one year prior to the sampling. The female
patient was not pregnant.
Subgingival plaque samples were taken for antibiotic
resistance analysis. At least the two deepest periodontal
pockets with bleeding on probing were selected for
microbiological sampling. Supragingival plaque was
removed, the sampling site was isolated using cotton
rolls and gently dried with air. A sterile paper point was
inserted to the bottom of the pocket, left in place for
20 s and placed in 0.5 ml of thioglycolate broth (bi-
oMrieux, Genf, Switzerland; Casas et al., 2007).
Microbiological procedures
Immediately after sampling, pooled paper points were
vortexed for one minute and serially diluted in thioglyco-
late broth. For the determination of the total anaerobic
bacterial count, 100 mL of the dilutions were plated on
Columbia blood agar plates (Columbia Agar Base [BBL
Becton Dickinson, Allschwil, Switzerland] enriched
with 4 mg/L hemin, 1 mg/L menadione, and 50 ml/L
human blood).
For quantifcation of the proportion of microorgan-
isms resistant to either amoxicillin and/or metronida-
zole, Columbia blood agar plates supplemented with the
following concentrations of the respective antimicrobial
agent were used: 3 mg/mL amoxicillin (Fluka, Buchs,
Switzerland), 8 mg/mL amoxicillin, 8 mg/mL metro-
nidazole (Fluka), 16 mg/mL metronidazole, 3 mg/mL
amoxicillin plus 8 mg/mL metronidazole or 8 mg/mL
amoxicillin plus 16 mg/mL metronidazole. The con-
centrations of the antibiotics were adopted from van
Winkelhoff et al. (2000) and/or the Clinical Laboratory
and Standards Institute (2007). All plates were incubated
anaerobically (10% CO
2
, 10% H
2
, 80% N
2
) at 36C
for 14 days and the colony forming units (CFUs) were
determined.
Results
Microbial fndings
Microbiological data are presented in Table 2. The
total anaerobic plaque count (CFU) ranged from 3.1
x 10
6
to 7.2 x 10
7
among the plaque samples, and the
percentage of black-pigmented bacteria ranged from
40 to 80%. All samples showed a decrease of bacte-
rial growth on agar by approximately 1 log with both
concentrations of the antibiotic agent (8 mg/mL and
16 mg/mL). All agar plates supplemented with 3 mg/
mL amoxicillin showed a reduced bacterial growth by
log 2.4, whereas two out of four samples revealed no
growth on the plates supplemented with 8 mg/mL of
amoxicillin (Table 2). On agar plates supplemented with
the combination of amoxicillin and metronidazole, no
anaerobic bacterial growth was detected even at lower
antibiotic concentrations.
Additive and/or synergistic in vitro effect of antibiotics 13
Figure 1. Patient N 2 was diagnosed with generalized aggressive periodontitis due to extensive bone loss at the
age of 32 years. a) Clinical intraoral photographs; b) Full-mouth periapical radiographs
Figure 1a.
Figure 1b.
Table 1. Profle of study patients and clinical characteristics.
BOP, bleeding on probing; GAgP, generalized aggressive periodontitis; GChP, generalized chronic periodontitis
Patient Age Periodontal
diagnosis
Smoking status Number of
teeth
Number of sites with PPD
6 mm
Number of
sites with BOP
+
1 45 GAgP Former smoker
30 pack years
29 165 174
2 32 GAgP Current smoker
15 pack years
29 92 133
3 38 GAgP Current smoker
17 pack years
25 69 96
4 48 GChP Current smoker
30 pack years
27 25 46
BPB, black-pigmented bacteria; CFU, colony forming units
Table 2. Microbiological characteristics and results of the antibiotic susceptibility analyses.
Bacterial growth on
agar plates
(control)
Bacterial growth on agar plates supplemented with different concentrations of metronidazole
or amoxicillin
Patient CFU % BPB CFU
amoxicillin
3 g/mL
CFU
amoxicillin
8 g/mL
CFU
metronida-
zole
8 g/mL
CFU
metronida-
zole
16 g/mL
CFU
amoxicillin 3 g/mL
+metronidazole
8 g/mL
CFU
amoxicillin 8 g/mL
+ metronidazole
16 g/mL
1 4.0 x 10
7
40 9.0 x 10
4
- 6.0 x 10
6
1.5 x 10
7
- -
2 1.0 x 10
7
50 8.0 x 10
3
1.0 x 10
4
6.0 x 10
5
6.0 x 10
5
- -
3 3.1 x 10
6
40 8.4 x 10
4
- 6.0 x 10
5
1.3 x 10
6
- -
4 7.2 x 10
7
80 4.0 x 10
5
3.0 x 10
5
1.3 x 10
6
1.5 x 10
6
- -
Discussion
The present preliminary study using subgingival plaque
samples demonstrated reduced bacterial growth in the
presence of low concentrations of metronidazole or
amoxicillin, while higher amoxicillin concentrations
inhibited bacterial growth in two out of four samples.
Interestingly, the combination of metronidazole and
amoxicillin was effective against microorganisms in all
subgingival plaque samples at lower antibiotic concen-
trations. This in vitro observation suggests an additive
or synergistic mode of action for these agents, which
is likely to be benefcial for infection control, as dem-
onstrated by recent clinical studies (van Winkelhoff et
al., 1989; Buchmann et al., 2002; Rooney et al., 2002;
Guerrero et al., 2005; Kaner et al., 2007a; Kaner et al.,
2007b).

It may be hypothesized that the targeted use of
this additive/synergistic effect, which is either based on
growth inhibition or on bacteriocidal effects, may offer
a strategy against the development and/or the control
of resistant strains.
The introduced method testing microbial suscep-
tibility to a frequently administrated combination of
antibiotics is a novel approach, which enlightens the
capacity of additive and/or synergistic effects between
the two substances. A synergistic effect of two anti-
biotics needs to be evaluated on a species level, and
was documented for Aggregatibacter actinomycetemcomitans
(Pavicic et al., 1994a; Pavicic et al., 1994b). The authors
suggested a higher rate of metronidazole uptake by
bacterial cells simultaneously incubated with amoxicil-
lin. Resistance of anaerobic bacteria to metronidazole
hardly ever occurred (Seifert and Dalhoff, 2010). In
the current material, bacterial growth was detected in
all four subgingival plaque samples, which is indicative
of metronidazole-resistant strains and emphasizes the
need for susceptibility testing in selected patients with
infections involving anaerobic bacteria. The results of
the current study should be, however, interpreted with
caution due to the limited number of subjects included,
and the lack of specifc bacterial strain characterisation.
However, the mixed subgingival plaque samples used
here represented the expected general characteristics
in terms of relative proportions of back-pigmented
anaerobes in the total culturable fora.
This preliminary study was restricted to current
or former heavy smokers, who have an increased risk
for the onset and progression of periodontal diseases
(Warnakulasuriya et al., 2010). Cigarette smoking is likely
to affect the composition of the oral microfora due to
a decrease in oxygen tension in periodontal pockets,
and may promotes a selection of anaerobic bacteria
(Hanioka et al., 2000). However, the literature has been
indecisive as to whether a specifc smoking-associated
microbial profle exists (van Winkelhoff et al., 2001; van
der Velden et al., 2003). Interestingly, recent evidence
from a randomized controlled trial suggests a beneft
of adjunctive antimicrobial therapy with metronidazole
and amoxicillin in the non-surgical periodontal treat-
ment of smokers with chronic periodontitis (Matarazzo
et al., 2008).
The culture technique used in the current inves-
tigation may have some shortcomings: (i) restricted
to growth of viable bacteria, (ii) strict sampling and
transport conditions essential, (iii) specifc laboratory
equipment and experienced personnel required for
bacterial culturing, (iv) time needed for bacterial growth
on appropriate media, (v) specifc pathogens in the
subgingival plaque may not be detected. However, the
main advantage of the technique used is the probability
of an analysis of bacterial resistance against the com-
bination of antibiotics, in particular against amoxicillin
and metronidazole. The diversity of the oral microfora,
reaching up to 700 different bacterial species (Kazor et
al., 2003), makes it impossible to analyze every single
bacterial strain regarding a genetic profle encoding for
antibiotic resistance. In addition, the molecular mecha-
nisms of bacterial resistance to antibiotics are quite far
from being completely understood. Therefore, the an-
tibiotic susceptibility of a subgingival plaque sample or
of putative periodontal pathogens needs to be analyzed
by conventional culture techniques (Armitage, 2003).
A major concern of the presented approach is the
natural bioflm association of the subgingival bacterial
samples analysed. A bioflm is a diffcult therapeutic
target because of its three-dimensional structure, which
protects the bacteria from the host response as well as
from antimicrobial agents (Socransky and Haffajee,
2002; Eick and Pfster, 2004). The methodology of
the present report allowed the interactions between
culturable microorganisms, but no attempt was made
to mimic other characteristics of the subgingival plaque.
Different results may be expected when a bioflm of
mixed microbial samples is formed on an appropriate
substrate prior to their susceptibility testing. However,
such an approach is currently not available. The chosen
methodology aims to provide an approach for clinically
relevant susceptibility testing.
According to the contemporary understanding of
the pathogenesis, periodontal diseases are caused by
an opportunistic infection with a conglomerate of
potentially periopathogenic microorganisms organized
in the subgingival bioflm. A number of different test
methods and procedures are available for qualitative
and quantitative microbiological diagnostics of putative
periopathogens. However, the pathogenic potential of
a certain putative periodontal pathogen against the host
can hitherto not be determined. Moreover, major indi-
vidual differences in the immune response are caused
by a number of acquired or genetic factors. Although
specifc bacteria have a periopathogenic potential or
Additive and/or synergistic in vitro effect of antibiotics 15
may initiate periodontal infammation, it is still diffcult
to determine the microbiota responsible for the onset
and progression of disease in the individual subject.
Thus, in the diagnosis and therapy of periodontal dis-
eases, microbiological identifcation and susceptibility
testing of single disease-associated strains may be of
limited value

(Mombelli et al., 2002; Sanz et al., 2004).
Instead or in addition to the conventional approach of
microbiological diagnostics, susceptibility testing of the
entire subgingival plaque sample may offer additional
valuable information for the choice of the antibiotic to
be administered adjunctively.
Improved therapy outcomes indicate that patients
with periodontal diseases - particularly those with highly
destructive forms (aggressive and/or advanced) - may
proft from an adjunctive antibiotic therapy using amoxi-
cillin and metronidazole (Guerrero et al., 2005; Kaner et
al., 2007a). However, due to the increased use of antibi-
otics and the alarming development of resistant strains,
antibiotics should be administered with care, and test-
ing the susceptibility of a given individuals microfora
may have an increasing importance (Walker, 1996; Van
Winkelhoff et al. 2005; Lakhssassi et al., 2005; Walter
and Weiger, 2006). Therefore, microbial testing can not
be recommended for routine dental practise. However,
some patients, in particular those in need of adjunctive
antimicrobial therapy, may proft from the information
about potential therapeutic targets (Armitage, 2003).
Susceptibility testing of whole subgingival samples to
metronidazole and amoxicillin and to their combination
seems to offer a rational diagnostic tool to the selection
of adjunctive antibiotic therapy. In the event of an un-
favorable response, i.e. bacterial growth on agar plates
supplemented with amoxicillin and metronidazole,
another antibiotic has to be tested and subsequently
applied for adjunctive antimicrobial therapy.
The current report about susceptibility analyses of
subgingival plaque samples was initiated as a proof-of-
principle study. The microbial results derived from the
audit of four cases may indicate a potential beneft for
further analysis in a larger clinical microbiological trial.
Acknowledgements
We gratefully acknowledge the technical assistance of
Mrs. Krystyna Lenkeit (Dental School, University Basel,
Switzerland) and the constructive criticism of Prof. em.
Jrg Meyer (Dental School, University Basel, Switzer-
land). There is no confict of interest.
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Correspondence to: Carlos Serrano, MSc., Specialist in Peri-
odontology, Department of Periodontal System, School of
Dentistry, Pontifcia Universidad Javeriana, Carrera 7 # 40-62,
Edifcio de Odontologa, Bogot, Colombia. E-mail: serrano-c@
javeriana.edu.co
Clinical and Microbiological Comparison of
Three Non-surgical Protocols for the Initial
Treatment of Chronic Periodontitis
Carlos Serrano, Nidia Torres, Angela Bejarano, Marcela Cavie-
des and Mara Eugenia Castellanos
School of Dentistry, Pontifcia Universidad Javeriana, Bogot, Colombia
Abstract
Objective: To compare the clinical and microbiological effects of three protocols for non-
surgical periodontal therapy, including full-mouth scaling and root planing plus systemic
antibiotics, on the treatment of chronic periodontitis patients. Methods: Twenty-nine
patients diagnosed with moderate to severe chronic periodontitis, selected according
to specifc criteria, were randomly assigned to one of three treatment groups: quadrant
scaling, full-mouth scaling, and full-mouth scaling supplemented by systemic antibiot-
ics. Antibiotic selection was based on the results of individual susceptibility testing.
Oral hygiene instructions and reinforcement were given during the study. All patients
received a clinical periodontal and microbiological examination at baseline and at re-
examination, 4-6 weeks after therapy. Means and standard deviations were calculated
and differences between groups were analyzed via the Kruskal-Wallis test, p < 0.05.
Results: The mean age of the study sample was 49.1 11.6 years old, and there were
17 men and 12 women. Patients treated with antibiotics showed antimicrobial suscep-
tibility for amoxicillin and doxycycline. All study groups showed a similar signifcant
improvement in periodontal parameters. Plaque scores were reduced in a range of
29.0% to 42.6%. Bleeding on probing was reduced by 34.8% to 55.0%; the reduction
for the full-mouth scaling group was larger. Mean reduction in pocket depth was 1.2
to 1.3 mm in all groups. Mean bacterial counts were reduced in the groups receiving
full-mouth treatment, but not in the quadrant treatment group. Conclusion: The three
protocols for non-surgical periodontal treatment demonstrated a similar positive effect
on clinical parameters; however, only full-mouth treatment groups showed a reduction
in anaerobic microbial counts at re-examination.
Key words: Chronic periodontitis, scaling and root planing, antibiotics, full-mouth scaling
Introduction
The main goal of periodontal therapy is to control the
infection associated with chronically infamed tissues
through a series of activities aimed at reducing the
bacterial destructive effect, such as oral hygiene in-
struction, subgingival debridement and surgical pocket
reduction. These protective measures, when reinforced
by meticulous self-performed oral hygiene and regular
professional maintenance, lead to the re-establishment
of periodontal health (Tunkel et al., 2002; van der Wejden
and Timmerman, 2002). Initial therapy for disease in-
cludes root surface instrumentation procedures, scaling
and root planing, usually performed on jaw quadrants
during a series of appointments. Systematic reviews on
non-surgical periodontal therapy have considered scal-
ing and root planing an effective treatment, measured
by clinical parameters such as reduction of bleeding
upon probing, reduction of probing pocket depth and
gain in probing attachment level (van der Wejden and
Timmerman, 2002; Hung and Douglass, 2002; Hallmon
and Rees, 2003). Studies on the microbiological effect
of scaling and root planing have shown that it produces
a marked disruption of the subgingival bioflm, leading
to decreased levels and proportion of sites colonized by
periodontal pathogens (Teles et al., 2006).
Considering that periodontal pathogens can be
found in different intra-oral niches besides periodontal
pockets, such as the tongue, the tonsils, the saliva and
other mucous membranes (van Winkelhoff et al., 1986;
Asikainen et al., 1991), and that translocation of patho-
gens from the above niches or untreated periodontal
pockets to recently treated pockets is possible (Quyrinen
et al., 1996), the Leuven University research group de-
JIAP 10-003 Serrano.indd 17 22/12/2010 09:41:22
veloped the full-mouth disinfection concept (Quyrinen
et al., 1995). This treatment protocol includes scaling
and root planing in two sessions within 24 hours, and
usage of different therapeutic forms of clorhexidine
for brushing the tongue, rinsing the mouth, spraying
the tonsils and irrigating pockets. Reports from the
original research group have concluded that full-mouth
disinfection has a benefcial effect in the treatment of
moderate and severe periodontitis, evidenced by 15%
greater reduction in bleeding on probing, 1.3-1.8 mm
greater reduction in probing pocket depth, and 1.5
mm additional gain in probing attachment level over
quadrant scaling (Mongardini et al., 1999; Quyrinen et
al., 2006). A modifcation of the full-mouth disinfection
protocol is one stage full-dentition scaling and root plan-
ing only, since it was identifed as the key component
responsible for the additional clinical and microbiologi-
cal improvements over traditional treatment (Quyrinen
et al., 2000). During recent years, several clinical reports
on the effect of full-mouth treatment concepts have
yielded contradictory fndings (Apatzidou and Kinane,
2004; Koshy et al., 2005; Wennstrom et al., 2005; Jervoe-
Storm et al., 2006; Zanatta et al., 2006). Two recent
systematic reviews concluded that differences between
full-mouth disinfection, full-mouth scaling and root
planing and traditional treatment were modest, so that
any of the three treatment modalities may be used for
initial therapy for chronic periodontitis (Lang et al., 2008;
Eberhard et al., 2008).
Considering the lack of signifcant differences be-
tween full-mouth treatment concepts and traditional
therapy referred to in systematic reviews (Lang et al.,
2008; Eberhard et al., 2008), and the additional clinical
beneft over scaling and root planing described for the
adjunctive use of systemic antibiotics (Herrera et al.,
2002; Haffajee et al., 2003), Cionca et al. (2009) studied
the effects of combining metronidazole and amoxicillin,
proper oral hygiene, and scaling and root planing over 24
hours in chronic periodontitis patients. The authors con-
ducted a placebo-controlled clinical trial of six months
duration, reporting signifcant clinical improvements for
both patient groups, but greater reduction in the number
of pockets > 4 mm and percentage of sites with bleed-
ing on probing for subjects receiving amoxicillin and
metronidazole. In conclusion, the authors stated that
systemic antibiotics signifcantly improved the clinical
outcome of full-mouth non-surgical periodontal therapy
and reduced the need for additional therapy.
The purpose of this study was to compare the clini-
cal and microbiological effects of three protocols for
non-surgical periodontal therapy, including full-mouth
scaling and root planing plus systemic antibiotics, on the
treatment of chronic periodontitis patients.
Materials and Methods
Study design
This was a parallel design, randomized clinical trial
performed at the Specialist Periodontal Clinic, School
of Dentistry, Javeriana University in Bogot, Colombia.
Approval for the protocol was obtained from the Ethics
Committee, Javeriana University; all patients signed an
informed consent form before the start of the study.
Patients
Twenty-nine patients were recruited from new referrals
to the Javeriana University, Specialist Clinic, according
to the following criteria: age ranging from 25-75 years;
possession of a minimum of 16 teeth; diagnosis of
chronic periodontitis (according to the criteria of the
International Classifcation System for Periodontal
Diseases [Armitage, 1999]) with severity ranging from
moderate to severe and multiple sites showing clinical
attachment loss 3 mm in all jaw quadrants; available
for participation in a follow-up examination after two
months. Patients were excluded if they had uncontrolled
systemic conditions, such as diabetes or cardio-vascular
disease, or required antibiotic coverage for treatment;
were pregnant or breast-feeding; were taking medica-
tion that could affect the periodontal condition or had
received antibiotic therapy during the previous three
months; had suspected or confrmed allergy to anti-
biotic agents, including -lactam or tetracycline group
antibiotics; or were current smokers, defned as having
a consumption rate of 10 cigarettes per day.
Experimental design
Enrolled subjects were randomly assigned by a com-
puter-generated table to one of three non-surgical
treatment modalities (Research Randomizer, Social
Psychology Network, 1997-2009):
Control group (Q): scaling and root planing quadrant
by quadrant at weekly intervals.
Full-mouth scaling and root planing (FM): full-
mouth scaling and root planing performed over two
consecutive days.
Full-mouth scaling and root planing plus antibiotics
(FMa): full-mouth scaling and root planing performed
over two consecutive days combined with the adminis-
tration of systemic antibiotics determined by suscepti-
bility testing for each subject.
All patients had a clinical examination and micro-
biological sampling before any treatment procedure
was performed (baseline), and at a period 4-6 weeks
after the last appointment for scaling and root planing
(re-examination).
Clinical and Microbiological Comparison of Three Non-surgical Protocols for the Initial Treatment of Chronic Periodontitis 19
Clinical examination
Clinical measurements of bleeding on probing, prob-
ing pocket depth and clinical attachment level were
performed on all present teeth at six tooth surfaces.
Four surfaces were examined for the OLeary plaque
score [percentage of presence/absence of plaque using
a disclosing solution: mesial, buccal, distal and lingual
(OLeary, 1972)]. Probing pocket depth (PPD) was
measured with a manual periodontal probe to the closest
millimeter. Bleeding on probing (BoP) was recorded as
the percentage of sites bleeding after probing pocket
depth measurements. Specifc analysis was performed
for moderate pockets (5 - 6 mm), and for deep pockets
( 7 mm). The gingival margin (GM) level was measured
from the gingival margin to a reference point, either the
cemento-enamel junction or the margin of a restora-
tion. In case of gingival recession, the gingival margin
level has a negative value. The probing attachment level
(PAL) was measured as GM PD. Reduction in the
percentage of sites with PPD 4 mm from baseline to
re-examination was recorded.
Microbiological examination
After cotton roll isolation and removal of supragingival
plaque, pooled microbial samples were taken with paper
cones from the deepest periodontal pocket in each quad-
rant for 15 seconds (Mombelli et al., 1991). Samples were
placed in vials containing anaerobic VMGA III transport
medium (Mller, 1966) and transferred for processing.
At the microbiological laboratory, samples were
vortex-mixed for 30 seconds and serially diluted 10-fold
fve times. One hundred L of 10
-1
dilution was plated
on blood agar and incubated for three days under aerobic
conditions. One hundred L of 10
-4
dilution was plated
on anaerobic Wilkins-Chalgren agar (Oxoid, United
Kingdom); plates were incubated for seven days at 37 C
in 80% N
2
, 10% CO
2
and 10% H
2
. Colony forming units
(CFU) were enumerated on blood and Wilkins-Chalgren
agar plates after the period of incubation. Presumptive
identifcation of periodontal pathogens was performed
based on colony morphology, Gram staining, aerotoler-
ance test and a commercial identifcation micromethod
system (RapID ANA II, Oxoid, United Kingdom).
Patients randomly assigned to the FMa group had
an antimicrobial susceptibility testing on identifed peri-
odontal pathogen colonies, mainly Porphyromona gingivalis,
Prevotella intermedia, Fusobacterium nucleatum and Wollinela
spp. Five different commercially available antibiotic strips
were used: amoxicillin, metronidazole, azithromycin,
tetracycline and doxycycline (E-test, AB Biodisk, Solna,
Sweden). Viable pure colonies were homogenized in
0.85% saline solution and adjusted to the MacFarland
turbidity standard 1.0. Using a sterile glass rod, 0.1 mL
of the inoculum was spread over Wilkins-Chalgren agar
plates and allowed to dry for 15 minutes. E-test strips
were gently placed over the agar surface and incubated
under anaerobic conditions for three days. The intersec-
tion between the zone of bacterial inhibition and the
E-test strip represented the minimal inhibitory con-
centration (MIC). The antibiotic with the lowest MIC
was selected to be used; if several tests were made for
the same patient the antibiotic with the lowest average
MIC was chosen.
Treatment procedures
Scaling and root planing were performed by three
periodontal graduate students (AB, MC and MEC).
The FM and FMa received scaling and root planing on
two consecutive days; in addition, for the FMa group
the antibiotic showing the lowest minimal inhibitory
concentration was prescribed for a one-week period.
The control group (Q) received scaling and root plan-
ing in four sessions, quadrant by quadrant, at one-week
intervals. All scaling was performed using manual cu-
rettes (Hu-Friedy, Chicago, IL, U.S.A.) and ultrasonic
magnetostrictive instruments (Cavitron, Dentsply, York,
PA, U.S.A.) without any time restriction.
At the baseline examination, all patients were given
detailed oral hygiene instructions, including toothbrush
and dental foss or inter-dental brush use. No mouth
rinses were used during the study. Patients received oral
hygiene reinforcement at weeks 2 and 4. Teeth judged
ready to be extracted due to poor periodontal condition
were extracted and not included for analysis; restorations
with overhangs were replaced during treatment.
Statistical analysis
Mean and standard deviation values for the OLeary
plaque score, percentage of BoP, PPD, PAL and percent-
age of pockets were calculated for each subject. Mean
and standard deviation of logarithmically transformed
CFU counts were calculated. The changes within groups
from baseline to re-examination were analyzed using the
paired Wilcoxon test. The differences between groups
were analyzed using the Kruskal-Wallis test. The level
of signifcance was set at p < 0.05.
Results
A total of twenty-nine patients completed the clinical
study: 10 patients in the control Q group, nine patients
in the FM group, and 10 patients in the FMa group.
The mean age of the patient sample was 49.1 11.6
years old; there were 17 men and 12 women. Twenty-six
patients were non-smokers, two patients were smoking
2 - 5 cigarettes per day, and a third patient smoked 2 - 3
cigarettes per week. Demographic characteristics of the
patient sample are described in Table 1.
Antimicrobial susceptibility testing results for the
10 subjects included in the FMa group revealed that in
four subjects, the lowest MIC value was for amoxicil-
Table 1. Demographic characteristics of the patient sample
Q, control; FM, full mouth scaling and root planing; FMa, full mouth scal-
ing and root planing plus systemic antibiotics
Q FM FMa
Number of patients 10 9 10
Mean age 46.6 (10.9) 52.8 (10.6) 48.2 (13.3)
Gender male/female 6/4 6/3 4/6
0
2
0
4
0
6
0
8
0
Q FM FMa
BL Final
Figure 3. Percentage of sites with probing pocket depth
(PPD) 4 mm

0
2
0
4
0
6
0
8
0
1
0
0
%
Q FM FMa
BL Final
Figure 1. Change in O`Leary plaque score

0
2
0
4
0
6
0
8
0
1
0
0
Q FM
BL Final
FMa
Figure 2. Percentage of sites with bleeding on probing
lin; for the other six subjects the lowest value was for
doxycycline. As a consequence, four subjects received
amoxicillin 875 mg twice a day for seven days; and six
subjects received doxycycline 100 mg once a day for
seven days.
Plaque scores
All study groups showed a high level of plaque ac-
cumulation at baseline before oral hygiene instruc-
tions were given, Q 56.7% 22.8, FM 77.8% 38.7
and FMa 47.3% 18.2. Nevertheless, with a random
group assignment the O`Leary plaque score was higher
for the FM group than for the other two groups. At
re-examination, all three groups showed a statistically
signifcant improvement in the O`Leary plaque score,
with mean reduction values ranging from 29.0% for
the FMa group to 42.6% for the FM; no statistically
signifcant differences were detected among the three
groups at re-examination (Figure 1).
Bleeding on probing
Percentage of sites bleeding on probing was equally
high for all three groups at baseline: at re-examination,
a statistically signifcant reduction in percentage of sites
bleeding on probing was present in all groups. For the
Q, the BoP percentage decreased from 78.7 26.3% to
44.0 29.0%, for the FM from 88.6 17.8% to 33.6
24.0%, and for the FMa from 80.0 14.5% to 46.3
27.9%. There were no statistically signifcant differences
when the three groups were compared; however, the FM
group obtained a 20% greater BoP percentage reduction
when compared with the other two groups (Figure 2).
Reduction in the percentage of pockets
At baseline, the percentage of sites with increased
PPD varied from 36.3% 20.9 for the FMa group, to
45.0% 28.1 for the Q group. A statistically signifcant
reduction in the percentage of sites showing PPD 4
mm was observed at re-examination compared with
baseline in all three groups. The reduction in percent-
age had a range from 12 to 17%; the greatest reduction
was obtained in the Q group, and the least in the FM
group. However, no statistically signifcant differences
were obtained between groups (Figure 3).
Probing pocket depth
The mean baseline PPD was similar in all three groups:
it varied from 5.0 0.6 mm for the Q group to 5.5 0.7
mm for the FM group. At re-examination, all three groups
showed a 1.2 - 1.3 mm signifcant reduction of PPD; no
signifcant differences were present among the groups.
When a separate analysis for pockets initially 5 - 6 mm
and 7 mm was performed, no signifcant differences
were found for mean change values among the three
groups, but greater variability in the healing response of
deep pockets was found for the Q group (Table 2, Figures
4, 5). Not all patients exhibited 7 mm deep pockets at
baseline: three patients in the Q group and one patient
each in the FM and FMa groups did not have pockets in
that depth category.
Probing attachment level
A signifcant gain in PAL of about 1.0 mm was measured
at re-examination for the three groups. No signifcant
differences were found among the groups.
Microbiological anaerobic CFU counts
Great variability in log-transformed anaerobic CFU
counts characterized the subjects in the three groups,
which was refected in high standard deviation values.
As a partial consequence, no signifcant differences were
observed in CFU counts at re-examination compared
with baseline. A decrease in log-transformed CFU
counts was measured for the FM and FMa groups,
0.34 and 1.33 respectively. In contrast, a slight increase
was measured for the Q group, -0.41 log-transformed
CFU count. Nevertheless, no signifcant differences
were obtained among the three study groups (Figure 6).
Of interest, only in the FMa group were there patients
whose oral fora was below microbiological culture de-
tection levels for anaerobes at re-examination (Figure 6).
Discussion
The results of the present study showed that periodontal
therapy in all three study groups resulted in a signifcant
improvement of periodontal clinical parameters. The
percentage of BoP sites was reduced in the range of
34 - 55%, PPD was reduced by 1.2 - 1.3 mm, and the
PAL gain was approximately 1 mm. These changes in
Table 2. Mean probing pocket depth (SD) values according to 5 - 6 and 7 mm depth categories
Q, control; FM, full mouth scaling and root planing; FMa, full mouth scaling and root planing plus systemic antibiotics
Q FM FMa
5-6 7 5-6 7 5-6 7
Baseline 5.2 (0.1) 7.4 (0.3) 5.5 (0.2) 8.0 (0.8) 5.4 (0.2) 7.5 (0.4)
Re-examination 4.0 (0.6) 5.3 (1.6) 4.2 (0.9) 6.2 (0.8) 4.0 (0.7) 5.8 (1.1)
Change 1.2 (0.5) 2.1 (1.3) 1.3 (0.6) 1.8 (0.9) 1.4 (0.5) 1.7 (0.9)
Figure 6. Log-transformed anaerobic bacterial colony counts
0
2
4
6
Q FM FMa
BL Final
3
4
5
6
M
i
l
m
e
t
r
o
s
Q FM FMa
BL Final
Figure 4. Probing pocket depth reduction from baseline: 5 - 6
mm depth category
2
4
6
8
1
0
M
i
l
m
e
t
r
o
s
Q FM FMa
BL Final
Figure 5. Probing pocket depth reduction from baseline: 7
mm depth category
clinical parameters are in the same range as results of
systematic literature reviews on the effects of non-
surgical periodontal therapy (van der Wejden and Tim-
merman, 2002; Hung and Douglass, 2002). The majority
of subjects in the present study showed great severity
of periodontal disease, as over 40% of the surfaces
were affected by periodontal pockets with a mean PPD
range of 5.0 - 5.5 mm, and a large number of pockets
7 mm deep were present.
No significant differences were found between
the control group receiving quadrant scaling and root
planing, and the other two groups receiving full-mouth
scaling and root planing. This is in agreement with two
recently published systematic reviews on the effects of
full-mouth treatment concepts: they concluded that only
modest differences were present between quadrant and
full-mouth treatment (Eberhard et al., 2008; Lang et al.,
2008). Noteworthy, in the present study the FM group
had a 20% greater reduction in BoP percentage com-
pared with the other two groups; however, due to a large
standard deviation, this difference was not statistically
signifcant. The systematic review by Lang et al. (2008)
reported an opposite fnding, as the weighted mean dif-
ference for BoP percentage reduction was 8.45% larger
in the quadrant scaling groups.
Of interest, no additional clinical beneft was ob-
tained from systemic antibiotic administration even if
the antibiotic showing the lowest microbial inhibitory
concentration was selected. This is contradictory to
the conclusion of systematic reviews on the effects of
systemic antimicrobials as adjuncts to non-surgical peri-
odontal treatment. The review of Herrera et al. (2002)
reported a small additional gain in PAL of 0.3 mm and
additional reduction of PPD ranging from 0.05 to 0.6
mm for patients receiving systemic antibiotics. Specifc
signifcant additional effects were found for the use
of spiramycin regarding PPD change, and amoxicillin
plus metronidazole regarding PAL change. The review
of Haffajee et al. (2003) found that adjunctive systemic
antibiotics led to an additional gain in PAL of 0.29 mm
for pockets initially 4 - 6 mm deep, and of 0.45 mm for
pockets initially 7 mm deep. Separate analysis by an-
tibiotic type showed that tetracycline and metronidazole
had a signifcant adjunctive beneft, followed by bor-
derline results for the combination of amoxicillin plus
metronidazole. In the present study, no greater reduction
of PPD or gain of PAL was found in patients receiving
systemic antibiotics, even when considering specifc
categories of initial PPD. As a possible explanation for
the lack of any additional effect for systemic antibiotic
administration, patient selection or antibiotic regime
could be analyzed. The current sample age range was
wide (25 - 75 years old), which could lead to the inclusion
of subjects with different rates of disease progression
and tissue destruction, even if all patients exhibited
clinical characteristics of chronic periodontitis. The 10
patients included in the FMa group were distributed
to receive amoxicillin (four cases) or doxycycline (six
cases); this reduced number of subjects does not allow
analyzing the effect of each antibiotic in addition to
non-surgical treatment. The combination of different
antibiotics was not tested in the present study, even if
the combination of amoxicillin and metronidazole in
addition to scaling and root planing has been found to
improve the clinical outcome of periodontal therapy
on different populations (Pavicic et al., 1994; Winkel et
al., 2001; Guerrero et al., 2005). The combination was
not used for the present population due to the large
levels of antimicrobial resistance to metronidazole. It
may be that antibiotic regimens could have different
adjunctive clinical benefts based on population varia-
tion for microbial antibiotic susceptibility. Nevertheless,
healing in pockets initially 7 mm deep demonstrated
a smaller range of variability in the FMa than in the Q
group, where box plots for baseline and re-examination
nearly overlap. The less variable healing response in the
antibiotic group could lead to clinical differences during
a longer healing time.
Several methods of describing the effect of peri-
odontal therapy on microbiological parameters have
been used in the literature: for example, change in bac-
terial counts, proportion of colonized sites, or level of
specifc periodontal pathogens, including presence or
absence at different threshold values (Teles, 2006). The
systematic review by Lang et al. (2008) stated an equally
positive improvement in microbiological parameters
for quadrant and full-mouth scaling and root planing.
However, in the present study no improvement in bac-
terial counts was seen in the Q group, whereas both
full-mouth treatment groups showed decreased bacte-
rial counts, the change being larger in the group that
received antibiotics. Using similar methods, Quyrinen et
al. (2000) found a small decrease in microbial counts for
quadrant scaling, compared to a larger 1 logarithmic unit
decrease in full-mouth treatment protocols, a compara-
ble fnding to the present study. On the contrary, studies
that have used polymerase chain reaction techniques to
detect specifc periodontal pathogens before and after
periodontal treatment have not found signifcant dif-
ferences between quadrant and full-mouth treatment
groups (Jervoe-Storm et al., 2007; Koshy et al., 2005). An
exception occurred for Treponema denticola, which had a
larger reduction in the full-mouth treatment group in
the report by Apatzidou et al. (2004).
The articles by Cionca et al. (2009, 2010) performed
a clinical and microbiological comparison between full-
mouth scaling and full-mouth scaling supplemented by
systemic amoxicillin and metronidazole. The clinical
results showed a signifcant clinical improvement for
both treatment groups: bleeding on probing was re-
duced by 37 to 45%, PPD was reduced by 1.2 - 1.3 mm,
and gain in PAL was 0.7 to 0.9 mm., showing a similar
clinical improvement to the present study. The main
outcome of therapy in the Cionca et al. (2009) report
was the number of sites with PPD 4 mm and bleed-
ing on probing. This fgure was signifcantly reduced
in both treatment groups, with a statistically greater
reduction for the group receiving antibiotics: 4.4 versus
1.3 remaining bleeding pockets. The present study used
a different method, as the percentage of sites 4 mm
deep, independent of bleeding on probing, was calcu-
lated. The microbiological study by Cionca et al. (2010)
reported lower bacterial counts for both study groups,
without any signifcant difference between them, similar
to the present study. The addition of systemic antibiotics
produced a greater reduction in the detection frequency
of Aggregatibacter actinomycetemcomitans and P. gingivalis.
Signifcant levels of antibiotic resistance to peri-
odontal pathogens in samples taken from Colombian
patients has led to the suggestion of performing anti-
biotic susceptibility testing before adjunctive antibiotic
therapy (Ardila et al., 2010; Serrano et al., 2009). In
the present study, amoxicillin or doxycycline was used
for the treatment of the 10 patients included in the
FMa group. Few studies have analyzed the effect of
amoxicillin administration alone as an adjunct to non-
surgical periodontal therapy, while the combination of
amoxicillin and metronidazole is more common (van
Winkelhoff et al., 1992). It has been reported that the
combination regimen produced a larger improvement
in clinical parameters compared to placebo therapy,
especially for patients who were initially positive for A.
actinomycetemcomitans and P. gingivalis, and who became
negative at re-examination (Pavicic et al., 1994; Winkel
et al., 2001). However, a combination regimen was not
used in the present study, as bacterial isolates showed
signifcant resistance against metronidazole, a fnding
that has been described by other research groups in
the same geographic area (Jaramillo et al., 2005; Ardila
et al., 2010). The use of systemic doxycycline, 100 mg a
day, as an adjunct of periodontal therapy, has produced
additional benefts in the periodontal treatment of dia-
betic patients (Grossi et al., 1997; Martorelli de Lima et
al., 2004; Llambs et al., 2005). Lately, those prescribing
doxycycline have looked not only for its antimicrobial
effect but also for inhibition of matrix metalloprotein-
ases (Salvi and Lang 2005).
An inclusion criterion in systematic reviews about the
effects of full-mouth non-surgical periodontal therapy
has been study duration of 3 or 6 months (Eberhardt et
al., 2008; Lang et al., 2008). Nevertheless, in the present
study re-examination was performed after 4 to 6 weeks
in order to assess the need for surgical periodontal ther-
apy in patients affected primarily by severe chronic peri-
odontitis. A consensus report by the American Academy
of Periodontology stated that a 4- to 6-week interval
seems appropriate to assess the initial response to non-
surgical periodontal therapy (Ciancio, 1989). The review
article by Segelnick and Weinberg (2006) proposed to
perform re-evaluation of basic periodontal therapy 4 to
8 weeks after scaling and root planing, based on evidence
from clinical studies and the histology of periodontal
wound healing. However, Badersten et al. (1981, 1984)
reported that clinical improvement after therapy leveled
off after 3 - 4 months for moderate periodontal cases,
but the periodontal condition could continue to improve
even for 6 to 9 months in advanced periodontal cases.
The present study showed a trend toward larger PPD
reduction for deep pockets and greater microbial count
reduction in the group receiving full-mouth therapy
supplemented by antibiotics; probably this trend would
become signifcant in a longer healing time.
In the present study, scaling and root planing was
performed by periodontal graduate students. Different
literature reports showed that experienced operators
have better results regarding calculus removal during
non-surgical instrumentation than graduate students
(Brayer et al., 1989; Fleischer et al., 1989). Nevertheless,
results of the present study are similar to the outcome
of non-surgical therapy reported in systematic reviews
in the literature.
Conclusion
The three protocols for non-surgical periodontal treat-
ment demonstrated a similar positive effect on clinical
parameters; however, only full-mouth treatment groups
showed a reduction in anaerobic microbial counts at
re-examination.
Acknowledgement and confict of interest
The authors declare there are no conficts of interest.
This study was supported by a research grant from the
Research Promotion Offce, Javeriana University.
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International Academy of Periodontology Lviv, Ukraine
June 16-18, 2011

13th International Biennial Meeting

Please complete form and return to: Congress Secretariat, 36 Pasichna Str, 79038 Lviv, Ukraine,
Ms. Olena Uhryn phone: +38 (32) 2512039, fax: +38 (32) 2512151, e-mail: klinika@litech.lviv.ua

Name: __________________________________________
Institution: __________________________________________
Mailing Address: __________________________________________
City: ___________________ Zip: _______________ Country: _____________
Telephone: ______________ Fax: ________________ e-mail:_______________
Participation in Gala-dinner YES NO Accompanying guest (Gala-dinner only) YES NO

DO YOU NEED OUR HELP IN HOTEL RESERVATION, PLEASE MARK YOUR CHOICE
1. Opera
Single Double Junior Suite Luxury Apartment
2. Dnister
3. Vintage
4. George
5. Eurohotel
6. Cytadel
7. Swiss hotel
8. Viden

Please indicate date of arrival and departure:

Check-in:______________ Check-out:______________
CONGRESS FEE-US dollars BEFORE
02/15/2011
BEFORE
03/15/2011
AFTER
03/15/2011
Dentists 270.00 300.00 350.00
Dentists members of Ukrainian Oral Implantology
Association and International Academy of
Periodontology
250.00 280.00 300.00
Dental technicians 170.00 200.00 250.00
Dental technicians members of Ukrainian Oral
Implantology association and International Academy of
Periodontology
150.00 180.00 230.00
Dental hygienists and dentists assistants 120.00 150.00 170.00
Students 50.00 75.00 100.00
JIAP Liv reg.indd 27 23/12/2010 12:08:16

International Academy of Periodontology Lviv, Ukraine
June 16-18, 2011

13th International Biennial Meeting

HOTEL RATES*** (grivna)
Hotel Single double junior suite luxury apartments
Opera 800 / 950 1050 / 1250 1450 2250
Dnister 500 /
600/850
500 / 600 /
850
950 1500
Vintage 750 950 - 1550
George 600/650 600/650 750 850
Eurohotel 500 600 / 700 900 1300 / 1700
Cytadel 990/1390 1200 / 1600 - 2900
Swiss hotel 500 / 650 600 / 750 1100 / 1250 1500 / 2520
Viden 450 / 520 /
640
500 / 570 /
690
520 / 550 650 / 700

NOTE: please make hotel reservation before 1 February 2011

*** Do not forget to leave for yourself the copy of completed registration form
*** Please note that usually check-in and check-out time is 12 a.m.
*** Above hotel rates are valid for the moment of printing this announcement and could be
changed by hotel administration.
For more up to-date information please refer to organizing committee or look for second
announcement

1US$ = 8 grivna
Ukrainian National Bank exchange rate on 1/09/2010
JIAP Liv reg.indd 28 23/12/2010 12:08:16
IAP Membership Application Form
Please mark the category of membership for which you are applying.
**Please note: Student membership must be accompanied by an ofcial letter with an ofcial stamp from the
Dean or Director of Studies at their Institute**
METHODS OF PAYMENT:
Payment by credit card-Membership applications can be sent by fax 617-638-4799 or by mail.
Payment by check-must by a US Dollar Check-Drawn on a US Bank and made payable to
The International Academy of Periodontology
Visa or MasterCard
Name on Card: ...............................................................................................................................................................................................................................................
Card number: .............................................................................................................................................. Expiry Date: ............................................................
Signature: ..........................................................................................................................................................
Active
$60.00
Associate
$60.00
Student
$30.00
Institutional
$150.00
Corporate
$1,500.00
Name: ......................................................................................................................
.........................................................................................................................................
Postal Address: ..............................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
City: ............................................................................................................................
State: ........................................................................................................................
Zip/Post Code: ................................................................................................
Country: .................................................................................................................
Email: .......................................................................................................................
Telephone: ..........................................................................................................
FAX: ..........................................................................................................................
Membership entitles the individual to receive
the quarterly Journal of International Academy
of Periodontology, and attend IAP Congresses
at a discounted rate. The IAP has recently been
recognized as the official Periodontal arm of
the Federation Dentaire Internationale (FDI) and
collaborates with the FDI to provide speakers
for Continuing Education courses, particularly in
developing regions of the world.
I wish to apply to become a member of the
International Academy of Periodontology in one of
the following membership categories:
Active ($60.00 USD)- for any dentist who is
registered with a specialist postgraduate qualification
in Periodontology
Associate ($60.00 USD)- for any dentist who is not
qualified for Active membership, and any person
who is certified to practice dental hygiene, or perform
duties relevant to the practice of periodontics
Student ($30.00 USD)- for dental school graduates
who are presently in postgraduate training in
periodontology
Institutional ($150.00 USD)- for National Societies
and Educational organizations
IAP Membership to:
Boston University Goldman School of Dental Medicine, 100 East Newton Street G107, Boston, MA 02118
Phone: 617-638-4758 Fax: 617-638-4799. E-mail: bujiap@bu.edu. Web: www.perioiap.org
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The Evolution of Floss
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