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218]

Original Article

Comparative evaluation of
efficacy of three treatment
modalities – tetracycline fibers, scaling
and root planing, and combination
therapy: A clinical study
Aashima Bajaj Dang, Krishan Kumar Chaubey,1 Rajesh Kumar Thakur,1
Ranjana Mohan, Zoya Chowdhary, Richa Tripathi1

Department of Abstract:
Periodontology, Background: Tetracycline is one of the primary antibiotics prescribed for antimicrobial therapy in periodontics.
Teerthanker Mahaveer It has a broad spectrum of activity being effective against most bacteria as well as spirochetes. Due to limitations
Dental College and of systemic drug therapy, recent formulations of the drug for local administration in the subgingival area have
Research Centre, been introduced, including collagen fibers impregnated with tetracycline. Aims and Objective: To compare
1
Department of the effectiveness of tetracycline fibers alone or in combination with scaling and root planing (SRP) on clinical
parameters in chronic periodontitis patients. Materials and Methods: A total of twenty patients comprising of
Periodontolgy, Kothiwal
both sexes in the age group of 35‑60 years with chronic periodontitis were selected. Split‑mouth design was
Dental College and used, and three teeth from each patient with periodontal pocket measuring > 5 mm were selected which were
Research Centre, treated with different treatment modality. They were randomly divided into site A (SRP), site B (tetracycline
Moradabad, fibers only), and site C (combination therapy). Clinical parameters of plaque index (PI), gingival index (GI),
Uttar Pradesh, India pocket probing depth, and clinical attachment level (CAL) were recorded at 0, 30, and 45 days. The data
obtained was compiled and put to statistical analysis. Results: All the three groups showed improvement in PI,
GI, probing pocket depth, and CAL. Results of the study showed greater improvements in clinical parameters
in Group C compared to Group A and Group B. Conclusion: The results indicate that the adjunctive use
of tetracycline fibers with SRP is a clinically effective and simple nonsurgical treatment method to improve
Access this article online periodontal health.
Website: Key words:
www.jisponline.com
Chronic periodontitis, scaling and root planing, tetracycline fibers
DOI:
10.4103/jisp.jisp_52_17
Quick Response Code:
INTRODUCTION Mechanical debridement alone may fail to
eliminate the putative pathogens from the

C hronic periodontitis is an infection involving

Address for
correspondence:
Dr. Aashima Bajaj Dang,
Department of
Periodontolgy, Teerthankar
Mahaveer Dental College
and Research Centre,
Moradabad, Uttar Pradesh,
India.
E‑mail: aashima_
bajaj2001@yahoo.com
Submission: 04‑03‑2017
Accepted: 02‑09‑2017
the destruction of supporting tissues
surrounding the tooth.[1] There is considerable
evidence supporting the role of bacteria as
the etiology of periodontal disease. Elevated
numbers of subgingival microorganisms have
been associated with destructive periodontal
disease activity. The elimination or reduction
of microbial pathogens present in subgingival
plaque is one of the primary objectives of
periodontal therapy. Recognition of specific
role of certain bacteria in chronic periodontitis
has tended to consolidate ideas in therapeutic
management of such diseases. [2] Removal or
inhibition of subgingival plaque thus plays
an important role in the maintenance of oral
health.[3] The main goal of periodontal therapy
is not only to stop periodontal destruction but
also to prevent the recurrence of disease and
regeneration of lost tissues.[4]
pockets completely because of the location
of these organisms within gingival tissue or
in deeper areas inaccessible to periodontal
instrumentations and thus results in recurrence
of disease. Therefore, the selective removal or
inhibition of pathogenic microbes with systemic
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For reprints contact: reprints@medknow.com
How to cite this article: Dang AB, Chaubey KK,
Thakur RK, Mohan R, Chowdhary Z, Tripathi R.
Comparative evaluation of efficacy of three treatment
modalities – tetracycline fibers, scaling and root
planing, and combination therapy: A clinical study.
J Indian Soc Periodontol 2016;20:608-13.

608 © 2017 Indian Society of Periodontology | Published by Wolters Kluwer ‑ Medknow

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Dang, et al.: Tetracycline as an adjunct with scaling and root planing
or topical antimicrobial agents in combination with scaling and
root planing (SRP) is often considered as an effective approach
at specific disease active sites.
Drugs administered systemically are absorbed into the blood
stream and distributed throughout the body through the
circulation.[5] However, systemic drug therapy is limited by
adverse reactions such as toxicity, acquired bacterial resistance,
and drug interactions. Patient compliance is also a recognized
problem. In contrast, local administration of the drug allows the
therapeutic agent to be delivered at the diseased periodontal
site with increased therapeutic effect and minimal side effects.
However, topically applied drugs do not have sufficient time
to exert their bacteriostatic or bactericidal effect on targeted
microorganisms residing in the subgingival area.
To overcome all these problems, various local delivery[6]
methods for administering antimicrobial agents directly into
the periodontal pocket have been tested. These methods further
minimize the side effects of systemically administered drugs
and also maintain a high level of antimicrobial agents within the
gingival crevicular fluid over an extended period. Local drug
delivery avoids most adverse reactions and disadvantages with
little or no systemic effects. The local concentration achieved
may be much higher than that is possible through the systemic
route.[7] Among the antimicrobials used in periodontal therapy,
much attention has been focused on tetracycline.
Tetracycline offers a broad‑spectrum antimicrobial
activity and may be a useful adjunct to periodontal
therapy.[8] Tetracyclines are the most commonly prescribed
antimicrobials in periodontal therapy. The groups of
tetracyclines are generally considered to be more effective
against Gram‑positive bacteria than Gram‑negative bacteria
and display good activity against most spirochetes as well
as many anaerobic and facultative bacteria. High drug
concentrations have been reported in gingival crevicular
fluid making them particularly suitable for periodontal
applications. The findings of Golub showed that apart from
their antimicrobial action, tetracyclines may inhibit tissue
collagenase and therefore retard the breakdown of collagen as
seen in periodontal disease.[9] This was also confirmed by the
studies of Rifkin and Vermilo on the anti‑collagenase activity
of tetracyclines.[10] The other properties of tetracyclines are
inhibition of bone resorption, anti-inflammatory actions, and
to promote the attachment of fibroblasts and connective tissue
to root surfaces in periodontal therapy.Thus, tetracycline has
improved outcomes as an adjunct to nonsurgical and surgical
periodontal therapy. [11] Various systems for insertion of
tetracyclines into periodontal pockets have been introduced
which include hollow fibers, [12] ethylene vinyl acetate
copolymer fibers,[13] ethyl cellulose fibers,[14] acrylic strips,[15]
collagen preparations, [16] and hydroxypropylcellulose
films.[17]
A newer delivery system of tetracycline fibers within collagen
fibers “Periodontal Plus AB™” (Advanced Biotech Products,
Chennai) containing 25  mg of pure fibrillar collagen along
with 2 mg of tetracycline HCL has been introduced [Figure 1].
Since there are limited numbers of studies conducted with the
above concentration of tetracycline hydrochloride, the present
study was undertaken to determine the effects of tetracycline
Journal of Indian Society of Periodontology ‑ Volume 20, Issue 6, November-December 2016 609
in the treatment of chronic periodontitis when used alone and
in combination with SRP.
MATERIALS AND METHODS
A total of twenty human subjects comprising of both sexes,
aged 35–60 years, who came to the outpatient Department of
Periodontology were selected. The design of this study was a
randomized, controlled, split‑mouth study. A pro forma was
designed so as to have a systematic and methodical recording of
all the observations and information, and prior written consent
was attained from each patient. Approval for the study was
obtained from the institutional ethics committee.
Chronic periodontitis patients with minimum of three
periodontal pockets  (probing depth of  ≥  5  mm) in
different quadrants of the mouth who had not received any
periodontal therapy during the past 3 months were selected
as study participants. Patients with any history of systemic
diseases (cardiovascular disease, diabetes, hepatitis, and renal
disorder), taking antibiotics, and antibacterial mouthwashes
during the last 3 months, pregnant women or lactating mothers,
and those allergic to tetracycline or cyanoacrylate were not
included.
Site and tooth selection
Three teeth from each patient with periodontal pockets
measuring  ≥5 mm each in different quadrants of the
mouth (using split‑mouth design) were selected. The sites were
divided into 3 sites randomly. SRP was performed in site A;
whereas in site B, only tetracycline fibers were placed; and in
site C, both SRP as well as the tetracycline fibers were placed.
Clinical parameters
Before doing the SRP, each selected site was subjected to recording
of plaque index (PI) (Silness and Loe 1964), gingival index (GI) (Loe
and Silness 1963), pocket depth  (PD), and clinical attachment
level (CAL). For standardizing the measurement of PD and CAL,
customized acrylic occlusal stents were prepared [Figure 2].
Measurement of pocket depth
The stents were used to fix the position and alignment of
periodontal probe, and PD was measured to the nearest
millimeter from the gingival margin to the base of the pocket
using UNC‑15 probe (Hu‑Friedy, USA).
Measurement of clinical attachment level
CAL was measured from the reference point, i.e., the lower
border of the stent to the base of the pocket using UNC‑15
graduated probe nearest to one millimeter.
Clinical parameters were recorded at 0, 30, and 45 days.
Material used
The product Periodontal Plus AB consists of 25  mg of pure
fibrillar collagen containing approximately 2  mg of evenly
impregnated tetracycline HCL, USP/IP.
Periodontal therapy
After recording the clinical parameters, full mouth phase I
therapy was performed with the help of ultrasonic scaler and
Gracey curettes except site B.
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Dang, et al.: Tetracycline as an adjunct with scaling and root planing

Administration of tetracycline fibers Table 1: Baseline comparison of clinical parameters in

After the fibers were soaked in saline, they were then placed three groups
into the pocket with the help of periodontal probe with gentle Parameter Group A (n=20) Group B (n=20) Group C (n=20)
pressure. The fibers were completely inserted into the gingival Mean±SD P50 Mean±SD P50 Mean±SD P50
sulcus, and the gingiva was carefully adapted to close the
PI 2.33±0.56 2.00 2.33±0.56 2.00 2.33±0.56 2.00
entrance of the gingival margin [Figure 3]. The gingival margin GI 1.93±0.23 2.00 1.93±0.23 2.00 1.93±0.23 2.00
was sealed with Coe‑pak (Coe‑Pak™, CG American Inc. USA) CAL 9.30±1.69 9.00 9.25±1.62 9.00 9.10±1.55 9.00
to prevent ingress of oral fluids for at least 10 days. The patients PPD 5.95±1.19 5.50 5.75±0.85 6.00 5.80±0.89 6.00
were refrained from chewing hard and sticky food, flossing P50 – Median (50th percentile). SD – Standard deviation; PI – Plaque index;
on the treated site, and not to disturb the area with tongue, GI – Gingival index; CAL – Clinical attachment level; PPD – Probing pocket
finger, or tooth pick. depth

Statistical analysis Table 2: Comparison of clinical parameters in three

The values were represented in number (%) and mean ± standard groups at day 30
deviation. The baseline data were checked for normality Parameter Group A (n=20) Group B (n=20) Group C (n=20)
using Kolmogorov–Smirnov test. For intergroup and group Mean±SD P50 Mean±SD P50 Mean±SD P50
differences in clinical parameters, Kruskal–Wallis and
PI 1.29±0.45 1.00 1.49±0.58 1.25 1.33±0.46 1.00
Mann–Whitney U‑tests were performed, respectively. Interval GI 1.09±0.32 1.00 1.11±0.33 1.00 1.09±0.32 1.00
comparison was done using Wilcoxon signed‑rank test. The CAL 8.95±1.88 9.00 8.65±1.53 9.00 8.15±1.60 8.00
statistical analysis was done using SPSS (Statistical Package PPD 5.45±1.10 5.00 5.55±0.89 6.00 4.80±0.95 5.00
for Social Sciences) Version 15.0 software (IBM SPSS Statistics, P50 – Median (50th percentile). SD – Standard deviation; PI – Plaque index;
India). GI – Gingival index; CAL – Clinical attachment level; PPD – Probing pocket
depth

RESULTS
Table 3: Between‑group difference in clinical parameters
A total of 20 patients, 16 (80%) males and 4 (20%) females, age at day 30 (Mann–Whitney U‑test)
ranging from 35 to 53 years with a mean of 40.15 ± 4.52 were Parameter Groups A Groups A Groups B
included in the study. Most commonly involved tooth was versus B versus C versus C
#26 (n = 14) followed by #16 (n = 10). At baseline, all the four Z P Z P Z P
clinical parameters, namely, PI, GI, CAL, and PPD were observed PI 1.131 0.258 0.312 0.755 0.862 0.388
to be matched in all the three groups showing no significant GI 0.348 0.820 0.000 1.000 0.348 0.820
intergroup difference (P > 0.05) [Table 1]. At day 30, PI, GI, CAL 0.447 0.678 1.761 0.086 1.317 0.201
and CAL in three groups did not show a significant difference PPD 0.833 0.445 1.968 0.068 2.506 0.017
among groups  (P  >  0.05). However, for PD, a significant P – Level of significance (P<0.05). PI – Plaque index; GI – Gingival index;
intergroup difference was observed  (P  =  0.026)  [Table 2]. CAL – Clinical attachment level; PPD – Probing pocket depth
Statistically significant difference in PPD was observed
between Group B and C with higher P-value seen in Group Table 4: Comparison of clinical parameters in three
B on comparison with Group C. Between‑group comparisons groups at day 45
revealed no significant difference for all the comparisons except Parameter Group A (n=20) Group B (n=20) Group C (n=20)
for the comparison for probing PD between Groups  B and Mean±SD P50 Mean±SD P50 Mean±SD P50
C (P = 0.017) [Figure 4 and Table 3].
PI 1.15±0.37 1.00 1.25±0.44 1.00 1.15±0.37 1.00
GI 1.04±0.23 1.00 1.06±0.25 1.00 1.04±0.23 1.00
With reference to PPD, statistically significant intergroup CAL 8.95±1.88 9.00 8.55±1.61 8.50 8.00±1.59 8.00
difference was observed (P < 0.05). At day 45, PI, GI, and CAL PPD 5.40±1.10 5.00 5.55±0.89 6.00 4.75±0.97 5.00
in three groups did not show a significant difference among P50 – Median (50th percentile). SD – Standard deviation; PI – Plaque index;
groups (P > 0.05). However, for PD, a significant intergroup GI – Gingival index; CAL – Clinical attachment level; PPD – Probing pocket
difference was observed  (P  =  0.017)  [Table  4 and Figure 5]. depth
Higher values for PPD were seen in Group B and lower values
in Group  C  [Table  5]. In Group  A, for all the parameters, a inflammatory lesion in the supporting tissues and leading to its
fall in mean value was observed with time. The mean value destruction.[18] The prime objective of Phase I and II periodontal
for all the parameters was maximum on day 0 and minimum therapy is to remove the cause, i.e., plaque and its detrimental
on day 45 [Table 6]. In Group B, for all the parameters, a fall effects on periodontal structures. Local drug delivery system
in mean value was observed with time. The mean value for allows the therapeutic agents to be targeted to the diseased sites
all the parameters was maximum on day 0 and minimum and also avoids unnecessary exposure of the patient to systemic
on day 45  [Table  7]. In Group  C, a gradual decrease in the antibiotic therapy. In the present study, tetracycline was chosen
values of all clinical parameters from baseline to 45 days was as it has been proved to be effective in the management of
observed [Table 8]. periodontal diseases because of its properties.[19]

DISCUSSION In this study, the reduction in plaque and GI was observed

to be associated with proper home care by patients and was
Periodontal disease comprises of a group of oral infections reflected in respective decrease in PD and gain in loss of
with a prime etiology being dental plaque, resulting in an attachment. The reduction in PI scores may be attributed to

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Dang, et al.: Tetracycline as an adjunct with scaling and root planing

a b
Figure 2: (a) Customized occlusal stent with guiding groove UNC‑15 probe; (b)
measurement of pocket depth and clinical attachment level

12
Group A Group B Group C
10

Mean value±SD
Figure 1: Periodontal Plus AB (tetracycline fibers) 8

0
PI GI CAL PPD
Parameter

a b Figure 4: Representation of comparison of clinical parameters in three groups at

day 30
Figure 3: (a) Periodontal AB plus fibers soaked in saline; (b) insertion of fibers
inside the periodontal pocket
Table 5: Between‑group difference in clinical parameters
at day 45 (Mann–Whitney U‑test)
12 Parameter Groups A Groups A Groups B
Group A Group B Group C versus B versus C versus C
10
Z P Z P Z P
Mean value±SD

8 PI 0.785 0.433 0.000 1.000 0.785 0.433

GI 0.424 0.820 0.000 1.000 0.424 0.820
6 CAL 0.594 0.565 2.110 0.040 1.218 0.242
PPD 1.086 0.327 2.013 0.060 2.626 0.011
4 P – Level of significance (P<0.05). PI – Plaque index; GI – Gingival index;
CAL – Clinical attachment level; PPD – Probing pocket depth
2

0
Table 6: Change in clinical parameters as observed in
PI GI CAL PPD Group A at different time intervals
Parameter
Parameter Baseline Day 30 Day 45
Figure 5: Representation of comparison of clinical parameters in three groups at Mean±SD P50 Mean±SD P50 Mean±SD P50
day 45 PI 2.33±0.56 2.00 1.29±0.45 1.00 1.15±0.37 1.00
GI 1.93±0.23 2.00 1.09±0.32 1.00 1.04±0.23 1.00
CAL 9.30±1.69 9.00 8.95±1.88 9.00 8.95±1.88 9.00
the meticulous oral hygiene insisted on all the patients during PPD 5.95±1.19 5.50 5.45±1.10 5.00 5.40±1.10 5.00
the entire study period. It would possibly be explained on the P50 – Median (50th percentile). SD – Standard deviation; PI – Plaque index;
basis that the residual effect of the drug from its reservoir, GI – Gingival index; CAL – Clinical attachment level; PPD – Probing pocket
depth
that is periodontal pocket, and tissues in the vicinity, over a
prolonged period of time, disrupted the biofilm formation
on the tooth surface. Thus, oral hygiene status is reflected by With reference to intergroup comparisons at day 30
and 45, a statistically significant difference in clinical
screening, randomization, and balancing than that of disease
parameters was observed between Group B and Group  C,
severity on the basis of plaque scores. This particular finding with less improvement seen when fibers were used alone.
in our study signifies the clinical utility of SRP in changing the This observation simply reflects changes in composition of
microbial environment in and around the tooth surface. Heijl periodontal tissues, rather than gain of new attachment.[21] The
et al. observed similar improvement in clinical parameters with least reduction in probing PD in Group B can be explained by
all three treatment modalities.[20] the fact that the subgingival debridement was not performed

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Dang, et al.: Tetracycline as an adjunct with scaling and root planing

Table 7: Change in clinical parameters as observed in effects of subgingival insertion such as allergy, gingival
Group B at different time intervals erythema, pain, discomfort, periodontal abscess formation,
Parameter Baseline Day 30 Day 45 and oral candidiasis. However, owing to the minimal systemic
Mean±SD P50 Mean±SD P50 Mean±SD P50 uptake of the drug, no adverse reactions/complications were
noticed in any case participating in the present study. The
PI 2.33±0.56 2.00 1.49±0.58 1.25 1.25±0.44 1.00
GI 1.93±0.23 2.00 1.11±0.33 1.00 1.06±0.25 1.00
observation period in the present study was not long enough,
CAL 9.25±1.62 9.00 8.65±1.53 9.00 8.55±1.61 8.50 so further long‑term prospective studies should be encouraged
PPD 5.75±0.85 6.00 5.55±0.89 6.00 5.55±0.89 6.00 to elucidate the true results/outcomes of local drug delivery
P50 – Median (50th percentile). SD – Standard deviation; PI – Plaque index; in the management of periodontal diseases.
GI – Gingival index; CAL – Clinical attachment level; PPD – Probing pocket
depth
CONCLUSION

Table 8: Change in clinical parameters as observed in The study demonstrates that application of tetracycline
Group C at different time intervals fibers after debridement is more effective and beneficial to
Parameter Baseline Day 30 Day 45 patients suffering from chronic periodontitis, with results
demonstrating an improvement in periodontal parameters.
Mean±SD P50 Mean±SD P50 Mean±SD P50
PI 2.33±0.56 2.00 1.33±0.46 1.00 1.15±0.37 1.00
Financial support and sponsorship
GI 1.93±0.23 2.00 1.09±0.32 1.00 1.04±0.23 1.00
CAL 9.10±1.55 9.00 8.15±1.60 8.00 8.00±1.59 8.00 Nil.
PPD 5.80±0.89 6.00 4.80±0.95 5.00 4.75±0.97 5.00
P50 – Median (50th percentile). SD – Standard deviation; PI – Plaque index; Conflicts of interest
GI – Gingival index; CAL – Clinical attachment level; PPD – Probing pocket There are no conflicts of interest.
depth
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