JOURNAL READING ENGLISH SESSION

Localized probiotic-guided pocket recolonization in the treatment of chronic

periodontitis: a randomized controlled clinical trial
PRESENTER : Savana Ersa SUPERVISING LECTURER : Aini Hariyani Nasution, drg.,
NIM . 207160013 Sp.Perio(K)

DENTAL SPECIALTY EDUCATION PROGRAM OF PERIODONTICS

FACULTY OF DENTISTRY
UNIVERSITY OF SUMATERA UTARA
 PENDAHULUAN

Conventional management chronic

periodontitis (CP) supragingival and Reduction  temporary and recolonization
subgingival mechanical debridement with of the pocket with more virulent
supervised oral hygiene maintenance periodontopathogens
decrease of the subgingival bacterial load

Adjunctive treatments to scalling and root

planing (SRP) systemic and local
antibioticslimitations

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 PENDAHULUAN…

Treatment concept • Changes in subgingival pocket

microbiota that result from a prevent
deliberate application of beneficial recolonization of
periodontal pockets
guided pocket bacterial species subgingivally
recolonization (GPR) following SRP

GPR capitalizes on
• conversion of the dysbiotic pocket compretitive
probiotics in microbiome  beneficial
exclusion,
immunomodulation,
periodontal therapy and passive
 occupation of
adhesion sites by
probiotics

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 studies exploring the use of probiotics  mainly Lactobacillus species,

as an adjunct to SRP for periodontitis patients in the form of lozenges, chewing gums, toothpaste,

powder, rinses, and milk formulations.

studies  the role of probiotics in GPR are limited

the first study exploring the role of probiotics in GPR clinically

MMP 8 biomarkers P. gingivalis (arginine- nitric oxide

specific gingipains) [NO]

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 Strain Lactobacillus, inhabitants of the oral cavity common  reduce gingival
inflammation, decrease P. gingivalis

Multiple studies  MMP-8  major biomarker  assessing periodontal

inflammation and response to periodontal therapy in oral fluids including GCF

Virulence factors of P. gingivalis 

Gingipains  extracellular cysteine proteases responsible for the proteolytic
activity of P. gingivalis.
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 NO  reactive free radical produced from L-arginine
through the action of isoenzymes
• Excessive levels of NO in response to inflammatory stimuli lead to
cytotoxicity and periodontal tissue breakdown
Multiple studies changes in NO levels and corresponding
nitrosative stress in saliva were correlated with
periodontal clinical parameters in chronic periodontitis
patients

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 • local application of • establish a treatment
Lactobacillus reuteri  protocol for localized L.
changes in clinical reuteri application, to
outcomes, the local assess one-time placement
environment, microbial versus incremental
flora, and the host response placement, and to test the
through GPR efficacy of the protocol in
achieving GPR

Hypothesa Purpose

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 MATERIAL AND METHODS

Criteria

18-65 years old + chronic periodontitis,

October 2016 - March 2018

Inclusion Exclusion
criteria criteria

Systemically healthy
patients
Generalized CP with a
minimum with probing
pocket depth ≥ 5 mm
Severe periodontitis;
pregnant or lactating
women;smokers.

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 Persetujuan etis dari studi dan persetujuan yang diinformasikan

Sample size calculation

A sample size of 15 patients per group was required to detect a difference
of ≥10% in mean PPD reduction between the independent study groups

a sample size of 15 patients per group was calculated to detect a

difference of ≥10% in mean MMP-8 reduction with an SD of 10%

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 Experimental design

group 1 (SRP + applications at 1, 2,

placebo): and 4 weeks

application after 1
Forty-eight patients group 2 (SRP+single
week and placebo
were randomly application of
application at 2 and 4
divided into 3 groups probiotic [P]):
weeks

group 3
(SRP+incremental applications at 1, 2,
application of and 4 weeks
probiotic [PPP])

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 Formulations of treatment products

Probiotic was provided in form of free-flowing powder containing 5.9 billion colony-forming units (CFU) of
L. reuteri per gram and maltodextrin as a carrier

Methylcellulose  placebo

Randomization

Random assignment was performed by the study coordinator (RS) in ascending order at the enrollment visit

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 Blinding

• Three identical, sterile, dry Eppendorf tubes numbered 1, 2, and 3 (representing the treatment
sequence) were prepared to contain color- and texture-matched placebo or probiotic powder in equal
volumes.
• Biochemical technician who was blinded to the study protocol prepared these tubes

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 Outcome
variables

Primary PPD, MMP8

variables

Secondar
y CAL, PI, GI, BOP,NO, gingipain

variables

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 PI and GI  Loe and Silness
1 Demographic data were analyzed 2 BoP  Ainamo and Bay
PPD and CAL were scored on all
teeth,

3 patient the site with the

maximum pocket depth and that
fulfilled the inclusion criteriA

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 Biochemical measurements

• GCF was collected from the test site at baseline and at a 12-week follow up.
• After the removal of supra-gingival plaque, the test site was air-dried. Absorbent cotton rolls were used to maintain
isolation during GCF collection.
• Paper points  were gently inserted inside the pocket until a slight resistance was felt  held for 30 sec

• Paper points were immediately transferred to a sterilized micro-

centrifuge tube (Eppendorf tube) containing 500 μL of phosphate-
buffered saline at 4°C and stored at −80°C until assayed.

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 Treatment protocol

Intervention

all participants received detailed personal OH instructions;

 toothbrushing training using the modified Bass technique with a soft-bristle
toothbrush and fluoride-containing toothpaste

SRP and curette

One week after SRP, sequential probiotic/placebo powder was incrementally inserted in
the predetermined test site using curettes gently

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 Recall visits were scheduled at weeks 2 and 4 for sequential placement of probiotic/placebo powder
according to the assigned treatment code

Clinical parameters were recorded at baseline and at 8, 12, and 24 weeks.

GCF was collected for the analysis of biochemical parameters at baseline and 12 weeks..

None of the enrolled participants showed any systemic or local signs of allergy or discomfort during
the intervention and follow-up period.

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 Statistical analysis

• Results were analyzed using descriptive statistics

• Student paired t-test

• Turkey honest

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 Clinical parameters

After the intervention,

Mean PPD and CAL scores
improvements were seen
were similar for all 3
in all 3 groups in the form
groups (P=0.831 and
of reduced PPD scores
P=0.177, respectively)
and increased CAL

Improvements in PPD
scores from baseline to
24 weeks following
treatment in all groups
were seen (P<0.001)
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 Biochemical parameters

MMP-8

The baseline levels for MMP-8 were similar in all 3 groups, with a significant decrease in values at 12 weeks
post-treatment

NO

NO values decreased significantly in all 3 groups at 12 weeks.

Rgps
Statistically significant concentrations of Rgps were detected in 31% of paper point samples

No significant differences in Rgps levels were observed among the 3 groups at baseline or at the 12-week follow up.

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 DISCUSSSION

GPR  L. reuteri - probiotic subgingivally

following SRP, and the corresponding Lactobacilli, the most common inhabitants of
changes in clinical and biochemical the oral cavity with known evidence of
parameters were observed --> 6 months. affecting the growth of oral microbiota
including periodontopathogens

Effective subgingival probiotic dosage has yet

to be established.
The present study utilized a 5.9 billion
CFU/gram concentration of L. reuteri

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 DISCUSSSION

• P. gingivalis Socransky's criterion periodontopathogen, as it is isolated from approximately 85% of CP disease

sites and is considered to be a keystone pathogen in CP progression.

• The present study showed significant improvement from baseline to 24

weeks in PPD and CAL scores in all 3 groups, with no significant intergroup
differences.
• The mean PPD reduction in group 2 (SRP+P) and group 3 (SRP+PPP) were
1.86±0.45 mm and 1.72±0.45 mm, respectively.

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 DISCUSSION

• The results of the present study regarding the reduction of PPD are comparable to those of studies by Vivekananda et
al. (1.31±0.49 mm; 42 days), using L. reuteri probiotic lozenges.

• Krasse et al. 2006 --> beneficial effects of L. reuteri on plaque in moderate-severe gingivitis patients within 14 days.

• In the present study, PI and GI --> significant differences between baseline and 8, 12, and 24 weeks in all 3 groups;
establishing the importance of SRP as benchmark therapy

• Group 3 (SRP+PPP) --> ignificant improvements in localized PI and GI scores of the test teeth.
• Notably, these improvements were significantly greater than those in group 2 (SRP+P) and group 1 (SRP+placebo).

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 DISCUSSION

an altered serum transudate, which changes its nature to an inflammatory exudate when signs of periodontal inflammation
become clinically evident

GCF as a unique source for quantitatively and qualitatively assessing the magnitude of bacterial challenge, host response
against bacteria, and level of homeostasis

GCF was the preferred periodontal

diagnostic fluid.

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 DISCUSSION

• Regarding MMP-8, a similar result was observed in the only previous study analyzing the effect of an
L. reuteri probiotic lozenge on MMP-8 levels in GCF by İnce et al. who showed a significant reduction in MMP-8
concentrations following intervention.

• Collagenolytic activity at the subgingival level was estimated to measure the immunomodulatory effects of
L. reuteri

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 CONCLUSION

SRP combined with sustained probiotic application leads to change in the local pocket
environment through a decrease in NO stress.

the results of this study show that incremental 3-time application of L. reuteri as a probiotic
led to improvements in clinical and biochemical parameters. This protocol can be a useful
adjunct to SRP in the non-surgical management of CP.

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PPDGS PERIODONSIA FAKULTAS KEDOKTERAN GIGI UNIVERSITAS SUMATERA UTARA
PPDGS PERIODONSIA FAKULTAS KEDOKTERAN GIGI UNIVERSITAS SUMATERA UTARA
 HASIL

Bagan alir penelitian digambarkan pada Gambar 1. Empat puluh lima dari 48 subjek dievaluasi untuk parameter klinis dan
analisis biokimia. Drop-out tidak mempengaruhi kekuatan penelitian, karena kami merekrut di luar ukuran sampel
minimum untuk melawan ttrition studi.
Karakteristik demografis dianalisis setelah studi selesai, dan kelompok-kelompok tersebut ditemukan cocok untuk
karakteristik yang tidak dapat dimodifikasi pada awal (P>0,05) (Tabel 1).

The study flow chart is depicted in Figure 1. Forty-five of the 48 subjects were evaluated for clinical parameters and
biochemical analysis. The drop-outs did not affect the power of the study, as we recruited beyond the minimum sample size
to counter study attrition. Demographic characteristics were analyzed after study completion, and the groups were found to
be matched for non-modifiable characteristics at baseline (P>0.05) (Table 1).

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 Sejauh pengetahuan kami, ini hanya studi kedua yang mengukur konsentrasi Rgps di GCF.
Dalam studi pertama, Rgps terdeteksi pada 49% pencucian GCF, 13% sampel titik kertas, dan 26% sampel strip
kertas.
Penelitian ini mendeteksi Rgps pada 31% sampel paper point, dengan penurunan terbesar ditemukan pada
kelompok 3, diikuti oleh kelompok 2.
Analisis biokimia semakin memperkuat bukti yang ada mengenai efek penghambatan L. reuteri pada P.
gingivalis, sebagaimana didukung oleh penelitian sebelumnya.
hasil penelitian kami memberikan bukti kuat untuk tindakan anti-plak dan anti-inflamasi L. reuteri di GPR ketika
digunakan sebagai tambahan sebagai probiotik subgingiva lokal, tetapi dukungan lemah untuk peran tambahan
L. reuteri dalam pengurangan PPD atau CAL gain dengan secara khusus mempengaruhi rekolonisasi saku.
Hasil ini menunjukkan peluang untuk studi in vivo lebih lanjut yang melibatkan ukuran sampel yang lebih besar,
follow-up yang lebih lama, dan suplemen tambahan permen untuk sepenuhnya memahami GPR sebagai
modalitas perawatan yang menjanjikan untuk poket periodontal.
Perlu disebutkan bahwa hasil ini tidak boleh digeneralisasi untuk strain probiotik lain, konsentrasi dan frekuensi
aplikasi yang berbeda, atau cara lainnya.

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 The 3 chosen biochemical markers (Rgps, MMP-8, and NO) represent 3
interrelated major etio-pathological factors of dysbiosis, inflammation, and the
host environment. L. reuteri produces an immunomodulin with powerful effect on
tumor necrosis factor alpha production and the antimicrobial compound reuterin,
and reduces oxidative stress to compete with other organisms in the host
environments to prohibit growth of bacteria . Surface-associated material from P.
gingivalis stimulates pro-inflammatory cytokines, promotes inducible NO
synthase expression, and increases the production of NO, generating nitrosative
stress among the subgingival microbiota. Studies have shown significant
reductions in the subgingival count of P. gingivalis after the administration of L.
reuteri in different forms

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 • GCF  transudat serum yang berubah, yang mengubah sifatnya menjadi eksudat inflamasi ketika tanda-
tanda inflamasi periodontal menjadi jelas secara klinis .

• 3 penanda biokimia yang dipilih (Rgps, MMP-8, dan NO) mewakili 3 faktor etio-patologis utama yang saling
terkait yaitu disbiosis, inflamasi, dan lingkungan host . L. reuteri menghasilkan imunomodulin dengan efek
kuat pada produksi alfa faktor nekrosis tumor dan senyawa antimikroba reuterin, dan mengurangi stres
oksidatif untuk bersaing dengan organisme lain di lingkungan inang untuk melarang pertumbuhan bakteri .
• Penelitian telah menunjukkan penurunan yang signifikan dalam jumlah subgingiva P. gingivalis setelah
pemberian L. reuteri dalam bentuk yang berbeda.

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 Guiding Periodontal Pocket Recolonization: a Proof of Concept
W. Teughels, M.G. Newman, […], and M. Quirynen+8View all authors and affiliations

Abstract
The complexity of the periodontal microbiota resembles that of the gastro-
intestinal tract, where infectious diseases are treatable via probiotics. In the
oropharyngeal region, probiotic or replacement therapies have shown some
benefit in the prevention of dental caries, otitis media, and pharyngitis, but
their effectiveness in the treatment of periodontitis is unknown. Therefore, this
study addressed the hypothesis that the application of selected beneficial
bacteria, as an adjunct to scaling and root planing, would inhibit the
periodontopathogen recolonization of periodontal pockets. Analysis of the data
showed, in a beagle dog model, that when beneficial bacteria were applied in
periodontal pockets adjunctively after root planing, subgingival recolonization
of periodontopathogens was delayed and reduced, as was the degree of
inflammation, at a clinically significant level. The study confirmed the
hypothesis and provides a proof of concept for a guided pocket recolonization
(GPR) approach in the treatment of periodontitis.

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 PI and GI
Intergroup baseline comparisons of PI, GI, and BoP scores showed no statistically
significant differences (Table 2) (P=0.547). Statistically significant differences between
groups at some time intervals were observed for the localized PI scores of the test teeth.
The mean PI was lowest in group 3 (SRP+PPP) and highest in group 2 (SRP+P) at 8, 12,
and 24 weeks. Pairwise comparisons of PI values between groups showed statistically
significant differences between groups 2 and 3 at 8 weeks (P=0.049), 12 weeks
(P=0.004), and 24 weeks (P=0.029). A statistically significant difference between group
1 (SRP+ placebo) and group 3 was observed at 24 weeks (P=0.031), and no statistically
significant differences were noted between groups 1 and 2 at any time interval.
Intragroup comparisons of PI scores over time are shown in Table 3.

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 The localized GI scores for the test teeth showed statistically significant
differences between groups at 8, 12, and 24 weeks (Table 2). Pairwise comparisons
of GI values between groups showed statistically significant differences between
groups 1 and 3 at 8 weeks (P=0.013), 12 weeks (P=0.005), and 24 weeks
(P=0.010). Differences were also observed in the GI scores between groups 2 and
3 at 8 weeks (P=0.035), 12 weeks (P=0.041), and 24 weeks (P=0.032). No
statistically significant difference was observed in the GI scores of group 1 and
group 2 at any time interval. Intragroup comparisons of GI scores over time are
shown in Table 3.
Improvements over time in the full-mouth PI and GI scores were observed in all 3
groups, with no statistically significant intragroup or intergroup differences.

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