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ORIGINAL RESEARCH Table of Contents   
Year : 2008  |  Volume : 19  |  Issue : 2  |  Page : 116-123
Evaluation of the regenerative potential of 25% doxycycline-loaded biodegradable membrane vs biodegradable membrane alone in the treatment of human periodontal infrabony defects: A clinical and radiological study


1 Department of Periodontics, Dr. HSJ Institute of Dental Sciences and Hospital, Panjab University Chandigarh, India
2 Department of Periodontics, Surendra Dental College and Research Institute, Sri Ganganagar, Rajasthan, India
3 Department of Periodontics, Punjab Government Dental College and Hospital, Amritsar, Punjab, India

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Date of Submission13-May-2007
Date of Decision26-Nov-2007
Date of Acceptance29-Nov-2007
 

   Abstract 

Background: Microbial colonization of the barrier membranes used for guided tissue regeneration is inevitable and can lead to delayed healing.
Aims: Antimicrobial coating of the membrane with 25% doxycycline paste has been attempted to prevent infection and achieve enhanced regeneration in periodontal infrabony defects.
Materials and Methods: Twenty-four patients with 2-walled or 3-walled infrabony defects were selected and randomly divided into two equal groups. Infrabony defects of group A were treated with a biodegradable membrane coated with 25% doxycycline while those of group B were treated with membrane alone. Clinical assessment of probing depth and attachment level and radiographic evaluation of the defect depth was done preoperatively and at 12 and 24 weeks postoperatively.
Statistical Analysis: The relative efficacy of the two treatment modalities were evaluated using the paired Student's t- test and the comparative evaluation between the two groups was done using the independent Student's t -test.
Results: Both the groups exhibited a highly significant reduction in probing depth and gain in clinical attachment level and linear bone fill at the end of 24 weeks. Comparative evaluation between the two study groups revealed a significant reduction in probing depth ( P = 0.016 * ) and linear bone fill ( P = 0.02 * ) in group A as compared to group B. Mean gain in attachment level was greater for group A than for group B but the difference was statistically nonsignificant ( P = 0.065 NS ).
Conclusions: The results suggest that doxycycline is beneficial in reducing membrane-associated infection and can potentiate regeneration through host modulation.

Keywords: Antimicrobial agents, host modulation, infection, microbial colonization, regeneration

How to cite this article:
Chaturvedi R, Gill AS, Sikri P. Evaluation of the regenerative potential of 25% doxycycline-loaded biodegradable membrane vs biodegradable membrane alone in the treatment of human periodontal infrabony defects: A clinical and radiological study. Indian J Dent Res 2008;19:116-23

How to cite this URL:
Chaturvedi R, Gill AS, Sikri P. Evaluation of the regenerative potential of 25% doxycycline-loaded biodegradable membrane vs biodegradable membrane alone in the treatment of human periodontal infrabony defects: A clinical and radiological study. Indian J Dent Res [serial online] 2008 [cited 2019 Sep 19];19:116-23. Available from: http://www.ijdr.in/text.asp?2008/19/2/116/40465
Contemporary periodontal therapy aims at achieving periodontal regeneration through the concept of 'guided tissue regeneration,' which leads predictably to the formation of a new attachment apparatus, thereby restoring the functional support to the teeth.

Guided tissue regeneration is a dynamic surgical procedure in which a barrier membrane is employed to mechanically seclude a protected space around the root surface and allow it to be selectively repopulated by the pleuripotent cells of the periodontal ligament. [1],[2] Another important function of the membrane is to divert the functional mechanical stresses from the coagulum-tooth interface and allow the undisturbed organization of the blood clot during the early and the most critical phase of wound healing. [3],[4],[5]

However, it was found that during the surgical and postoperative healing phases, both nonbiodegradable and biodegradable membranes could serve as a nidus for the growth of the microorganisms harbored in the oral cavity. Bacterial colonization of the membrane interfered with optimal healing, resulting in reduced regeneration. [6],[7],[8]

Studies have shown that coating the barrier membrane with antimicrobial substances could provide a high concentration of the antibiotic at the membrane site and thus achieve complete asepsis and enhanced regeneration. [9] Among the wide variety of antimicrobials that have been used to control infections following periodontal therapy, doxycycline has exhibited promising results.

Doxycycline is a potentially valuable antibiotic, with a broad spectrum of activity against numerous periodontal pathogens. It has the ability to concentrate in the gingival crevicular fluid at levels substantially greater than in serum [10],[11],[12] ; additionally, it also binds to the tooth surface to be slowly released in an active form, thereby prolonging its therapeutic effects. [13],[14] It demonstrates anticollagenolytic and antiproteolytic properties that aid osseous regeneration and also help in reducing periodontal disease progression. [15],[16],[17]

The membrane that we used in our study was oxidized regenerated cellulose, a commercially available haemostatic dressing in the form of a knitted fibrous mesh, which has been used as a barrier in the regenerative treatment of periodontal defects and congenital maxillary cleft reconstructive surgeries. [18],[19],[20],[21],[22],[23] On contact with blood, the mesh gets soaked and swells into a brownish-black gelatinous mass that incorporates the blood clot to form a blood-membrane continuum and, thus, aids in clot stabilization. It also displays bactericidal activity against a wide range of gram-positive and gram-negative organisms, including aerobes and anaerobes. [24]

In the present study an attempt has been made to clinically and radiographically evaluate the regenerative potential of 25% doxycycline-coated biodegradable membrane vs membrane alone in the treatment of human periodontal infrabony defects.


   Materials and Methods Top


Clinical trial

Twenty four patients with two-walled or three-walled infrabony defects, as determined by clinical and radiographic evaluation, were selected from among those reporting at the department of periodontology.

The patients selected were nonalcoholics, nonsmokers, and had no history of allergies or any systemic debilitating disease. All patients meeting the selection criteria were consecutively enrolled from February 2003 to January 2004.

Prior to surgery, these patients were subjected to oral prophylactic procedures, occlusal equilibration if required, and routine laboratory investigations; their oral hygiene status was reviewed till it was maintainable at a satisfactory level.

The clinical parameters assessed were probing depth and attachment level (to ascertain clinical attachment loss). Radiographically, the infrabony defect depth was ascertained by using a standardized radiographic technique and by measuring from a fixed reference point (the adjacent cuspal tip) to the most apical point of the base of the defect; a grid was used as an adjunct to the x-ray film to ensure accuracy in the measurements [25] [Figure - 1],[Figure - 2],[Figure - 3].

The selected patients were randomly divided into two groups: group A and group B, with 12 patients in each. Group A was the experimental group, where defects were treated by the placement of doxycycline-loaded membrane, while group B was the control, where the defects were treated by the placement of membrane alone.

Preparation of the membrane

Oxidized regenerated cellulose membrane (Surgicel ) was the resorbable membrane used for guided tissue regeneration. It was loaded with 25% doxycycline paste. The membrane was cut under aseptic conditions into an 'H' shaped piece. It was placed interproximally, with the broad ends facing the buccal and lingual/palatal flaps [20] [Figure - 5].

To prepare a 25% w/w doxycycline-loaded membrane, 100 mg of doxycycline hydrochloride dispersible tablet was dissolved in 0.4 ml of distilled water. [9] The paste thus formed was smeared onto the tooth-facing surface of the oxidized regenerated cellulose membrane following its placement in the infrabony defect [Figure - 6].

Surgical procedure

The patients were premedicated using 10 mg diazepam and 0.3 mg glycopyrrolate intramuscularly 45 min prior to the surgical procedure.

Envelope flaps were reflected following anesthesia (2% lidocaine + 1:2,00,000 adrenaline) so as to debride the infrabony defects prior to the regenerative procedure [Figure - 4]. After the designated membrane placement [Figure - 5],[Figure - 6], the flaps were repositioned and approximated with interrupted interdental sutures, using 3-0 black braided silk [Figure - 7].

Antibiotic therapy (amoxicillin 250 mg + cloxacillin 250 mg + lactobacillus 60 million spores) for 8 days, along with an anti-inflammatory agent for 3 days, was prescribed postoperatively. The patients were asked to follow dietary instructions strictly and perform adequate plaque control by rinsing with 10 ml of 0.2% chlorhexidine gluconate twice daily for 2 weeks postoperatively. Sutures were removed 1 week after surgery, and postoperative assessments of the clinical and radiographic parameters were done at 12 weeks and 24 weeks.


   Results Top


It was observed that the resorbable, oxidized regenerated cellulose membrane as well as doxycycline possessed excellent handling characteristics, were easy to manipulate, and were well tolerated by all the patients; there was no case of adverse tissue reaction, infection, or delayed healing reported during the course of the study.

The postoperative assessments for the parameters were done at 12 weeks and at 24 weeks. The observations recorded were subjected to statistical analysis. The mean values of probing depth [Table - 1], clinical attachment level [Table - 2] and infrabony defect depth [Table - 3] at the three points in time were evaluated. The efficacy of the two treatment modalities at 12 and 24 weeks postoperatively were evaluated using the paired Student's t-test since the observations at the two points in time were expected to be closely related to each other. The two groups, A and B, were then comparatively evaluated over the three time intervals, using the independent Student's 't' test for equal sample sizes since the samples were collected from randomly selected individuals from the same population at different times.

On analyzing the clinical criteria of reduction in probing depth in the two groups, it was seen that the use of doxycycline-loaded membrane provided a statistically significant reduction in probing depth at all the three points in time. The membrane used alone provided a statistically significant reduction in probing depth after 12 and 24 weeks postoperatively; however, a nonsignificant reduction was seen between 12 and 24 weeks postoperatively [Table - 4].

With regard to the parameter of clinical attachment level, the doxycycline-loaded membrane provided a highly significant gain in attachment level at all the three points in time. The membrane used alone also provided a highly significant gain in clinical attachment level after 12 and 24 weeks postoperatively, but a nonsignificant gain in attachment level was seen between 12 and 24 weeks postoperatively [Table - 5].

The linear bone fill for both the groups was statistically highly significant for all the three points in time [Table - 6].

On comparative evaluation of the two groups, the use of doxycycline-loaded membrane exhibited a greater reduction in probing depth than membrane used alone, and this difference was seen over the entire span of the study, i.e., between preoperative and 24 weeks postoperative was statistically significant (P = 0.016) [Table - 7].

The mean gain in attachment levels with doxycycline-loaded membrane was also greater than that seen with the membrane alone; however, the difference on comparative evaluation was found to be statistically nonsignificant at 24 weeks postoperative. (P = 0.065) [Table - 8].

Doxycycline-loaded membrane also provided a statistically significant linear bone fill as compared to the membrane alone over the span of the study from preoperative to 24 weeks postoperative (P = 0.02) [Table - 9].


   Discussion Top


Periodontal regeneration is now a major challenge in periodontal research and practice. It involves the use of regenerative therapy to restore the defects produced by the disease process. [26]

Occasionally, in guided tissue regeneration (GTR) therapy, there is a risk of barrier membrane contamination, either by the oral environment following its exposure or inside the healing wound which is highly prone to infection. The barrier material, due to its structural and textural characteristics, creates an ecological niche suitable for the growth of, and colonization by, the putative periodontopathogens. [27],[28] This not only prevents organization and integration with the connective tissue but also reduces the clinical attachment gain achieved with surgery. [6],[7],[8]

Successful prevention and treatment of periodontitis is contingent upon effective control of the resident microorganisms by complementing mechanical therapy with local or systemic antimicrobial treatment. [29],[30]

All local drug delivery systems aim at achieving high bactericidal concentrations of the antibiotic at the site of infection, concomitantly minimizing the risk of systemic side effects. [31]

As the concept of tissue engineering has developed, third-generation membranes have evolved, which not only act as barriers but also as delivery devices to release specific agents such as antibiotics, growth factors, adhesion factors, etc., at the wound site on a time or need basis in order to orchestrate and direct natural wound healing in a better way. [26] Antimicrobial coating of the barrier membrane is a novel approach to control the barrier membrane-associated infection as well as to achieve enhanced regeneration. [9],[32],[33],[34],[35],[36],[37]

Tetracyclines constitute a family of antibiotics that have been found to be highly effective against the putative periodontopathogens. Among them, doxycycline has exhibited encouraging results and, therefore, was the drug chosen for this study.

Oxidized regenerated cellulose has been evaluated as a reservoir for controlled drug-release systems and has been found to be capable of prolonged release of doxycycline in vivo without damage or alteration of its physical structure. [32],[38] The membrane is a knitted, fibrous mesh with porous structures, both at its surface and in the sublayer, allowing good cellular infiltration, better adaptation, and sufficient nutrient permeation.

On analyzing the results, the mean reduction in probing depths of group A as well as of group B were found to be statistically highly significant at 12 and 24 weeks postoperatively. The reduction in probing depth between 12 and 24 weeks postoperative was significant for group A but nonsignificant in the case of group B. Comparative evaluation of the two groups revealed that at the end of 24 weeks, the mean reduction in probing depths of group A was higher than that of group B, and the difference was statistically significant.

Similarly, the mean gain in attachment levels for the two groups showed statistically highly significant results over the entire span of the study, except between 12 and 24 weeks postoperative for group B, where the gain in clinical attachment was nonsignificant. When group A and group B were compared, although the mean value of group A was higher than that of group B, the difference was found to be statistically nonsignificant between preoperative and 24 weeks postoperative (P = 0.065). This value of P suggests that with a larger study sample, a statistically significant difference can be anticipated.

The mean linear bone fill for both the groups also showed an increase that was statistically highly significant over the study period; comparison of the two groups revealed a greater radiographic evidence of bone fill in group A over group B, with the difference being statistically significant.

It has been observed [39],[40] that, the maximum soft tissue healing of the periodontal tissues occurred in the first 3 months following surgery; during this period a fully epithelized gingival crevice with a well-defined epithelial attachment is formed and a functional arrangement of the supracrestal collagen fibers is established. The maturation of the collagen fibers, however, continues and is completed by 6 months, while bone regeneration is completed at 18 months postoperatively. In this study, an appreciable change in the hard tissue parameter - the linear bone fill - has been radiographically evidenced over the course (24 weeks) of this study.

The results of this study are consistent with those of Waleed et al ., [41] Pepelassi et al ., [42] Zarkesh et al ., [34] and Chang et al ., [9] all of whom have successfully used doxycycline as an adjunct to regenerative therapy. This highlights the adjunctive benefit of doxycycline, which is by virtue of its antimicrobial as well as its intrinsic host-modulatory action.

The bacteria that are usually associated with periodontal diseases predominantly reside in a multispecies biofilm. Doxycycline has been found to be highly effective in inhibiting biofilm formation by various strains of Prevotella intermedia, a key periodontopathogen. [43] An in vitro study on the effect of antimicrobial agents on planktonic and biofilm forms of  Staphylococcus lugdunensis Scientific Name Search shown that tetracyclines substantively lessened the amount of biofilm formed by 93% of the isolates. [44]

Doxycycline has the capability of conditioning dentine and also enables fibrin linkage, both of which favor the formation of a new attachment. [45],[46] It exhibits a high degree of substantivity by binding to the periodontally diseased root cementum and dentine; this then serves as a reservoir, slowly releasing the antibiotic in a biologically active form, and at antibacterial levels, into the adjacent environment for several days following its topical application. [13],[14]

Doxycycline and other tetracycline analogues have also been found to inhibit collagenase and other host-derived matrix-metalloproteinase (MMPs) which are released as the periodontal disease progresses. [15],[17] It protects α-1 proteinase inhibitor from proteolytic inactivation in the gingival crevicular fluid [16] and also inhibits the production as well as the scavenging of reactive oxygen radicals generated by the polymorphonuclear neutrophils. [47]

Doxycycline potentiates osseous regeneration in periodontal defects when locally administered due to its anticollagenolytic effect, which enhances the bone-forming ability via osteoblast cell chemotaxis and reduced bone resorption. Doxycycline has also been shown to initiate demineralization on the bone surface layer, which results in the release of osteogenic factors such as the transforming growth factor (TGF)-β, insulin-like growth factor (IGF), or the bone morphogenetic proteins (BMPs) that trigger bone induction. [9]

From a futuristic viewpoint, attempts can be made to harness the potential additive effects of a sub-antimicrobial dose doxycycline (SDD) [48],[49] or a chemically modified tetracycline (CMT) [50],[51] in conjunction with periodontal surgical procedures such as host modulation therapy (HMT), to block the pathways of periodontal tissue destruction as well as to enhance wound healing and regeneration.


   Acknowledgment Top


We express sincere thanks to Dr. A.S. Sethi, Professor, Punjab School of Economics, Guru Nanak Dev University, Amritsar, for his help with the statistical analysis of the data and its interpretation.

 
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Correspondence Address:
Rashi Chaturvedi
Department of Periodontics, Dr. HSJ Institute of Dental Sciences and Hospital, Panjab University Chandigarh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-9290.40465

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    Figures

  [Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5], [Figure - 6], [Figure - 7]
 
 
    Tables

  [Table - 1], [Table - 2], [Table - 3], [Table - 4], [Table - 5], [Table - 6], [Table - 7], [Table - 8], [Table - 9]

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    Abstract
    Materials and Me...
    Results
    Discussion
    Acknowledgment
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