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Table of Contents   
ORIGINAL RESEARCH  
Year : 2013  |  Volume : 24  |  Issue : 1  |  Page : 52-59
Effects of tetracycline-containing gel and a mixture of tetracycline and citric acid-containing gel on non-surgical periodontal therapy


Department of Periodontics and Implantology, Meenakshi Ammal Dental College, Chennai, Tamil Nadu, India

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Date of Submission02-Jan-2010
Date of Decision26-Feb-2010
Date of Acceptance16-Sep-2010
Date of Web Publication12-Jul-2013
 

   Abstract 

Aims and Objectives: The purpose of this study was to assess the clinical and microbiological effects of a newly developed root-conditioning gel system containing tetracycline and a mixture of tetracycline and citric acid on non-surgical periodontal therapy.
Materials and Methods: Four anterior teeth from four quadrants with a probing depth of 4-6 mm, in each of the 20 subjects with chronic periodontitis, were subjected to four different modalities of treatment. A total of 80 teeths were divided into four groups of 20 teeth each taken from separate quadrants, on the basis of one of the following four treatments: (1) Root planning alone in first quadrant (RP group); (2) tetracycline-containing gel in the second quadrant (TCG group); (3) root planning plus tetracycline-containing gel in third quadrant (RP + TCG group); (4) root planning plus a mixture of tetracycline and citric acid-containing gel in fourth quadrant (RP + TC-CAG group). Plaque index (PI), sulcular bleeding index, probing pocket depth, and clinical attachment level were measured for 0 day, 8 th week, and 12 th week, respectively. Subgingival plaque samples from each site were collected at the same visits and examined with dark field microscope for proportions of motile rods and spirochetes.
Results: From 0 day to 12 th week, PI, sulcular bleeding index, probing pocket depth, and clinical attachment levels decreased significantly in all the groups. From 0 day to 12 th week, RP + TC-CAG group showed a significantly higher change in the PI score. From 0 day to 12 th week, RP group showed a significantly higher change in sulcular bleeding index score. A significant decrease in probing pocket depth and gain in clinical attachment level was noted at 12 th week in RP + TC-CAG group compared to the other groups. A significant decrease in the proportion of motile rods was found primarily in the RP + TC-CAG group. There was a decrease in the proportion of spirochetes in all the groups.
Conclusion: The results indicated that the use of a mixture of tetracycline and citric acid-containing gel was effective in improving gingival health and in changing subgingival microflora.

Keywords: Citric acid, microbiology, non-surgical periodontal therapy, tetracycline

How to cite this article:
George RP, Kumar S, Ramakrishna T, Emmadi P, Ambalavanan N. Effects of tetracycline-containing gel and a mixture of tetracycline and citric acid-containing gel on non-surgical periodontal therapy. Indian J Dent Res 2013;24:52-9

How to cite this URL:
George RP, Kumar S, Ramakrishna T, Emmadi P, Ambalavanan N. Effects of tetracycline-containing gel and a mixture of tetracycline and citric acid-containing gel on non-surgical periodontal therapy. Indian J Dent Res [serial online] 2013 [cited 2020 Oct 22];24:52-9. Available from: https://www.ijdr.in/text.asp?2013/24/1/52/114949
Periodontal diseases are caused by oral microorganisms growing in dental plaque in gingival and subgingival periodontal niches. [1] While no single entity has been isolated in the etiology of inflammatory periodontal disease, bacterial plaque has been identified as a primary factor. The microbial flora of a periodontally diseased site exhibits increased populations of anaerobic motile rods and spirochetes, while the flora in a healthy site is predominantly coccoid cells and non-motile rods. [2]

Removal of such soft and mineralized plaque is, therefore, of paramount importance in the treatment of pathological conditions. [3] Initial treatment of periodontal disease may involve subgingival scaling and root planning to remove irritants from the root surfaces in an effort to reduce inflammation and promote a healthy periodontium. [2] The results of numerous studies indicate that the bacterial flora of a periodontally diseased site is altered with scaling and root planning. [4]

Clinicians and investigators in periodontology have suggested that periodontal diseases may respond to antimicrobial therapy. The rationale for the use of antibiotics in the management of periodontal diseases is based upon the concept that the primary cause of these diseases is bacterial. The use of local delivery of antibacterial agents to sites of active periodontitis has aroused considerable interest because of the possibility of achieving a maximum antibacterial concentration with minimal side effects. [5]

Root-surface conditioning by topical application of acidic solutions has been demonstrated to remove root instrumentation smear layer and also any remaining root surface contaminants. [6] Register [7] , Register and Burdick [8] reported enhancing of the new attachment by acid. One of the most widely used adjuncts is citric acid, which primarily removes the smear layer. Other agents such as tetracycline and EDTA have been reported to favor new periodontal attachment. This process renders the root biologically compatible to the adjacent tissues. [9]

The first local delivery product was tetracycline-containing fibers. Other locally delivered antibiotics used are doxycyline and minocycline. [10] Tetracycline has been shown to pass into the gingival fluid in man and dogs. Clinical studies using tetracycline and HCl have shown it to have an effective spectrum of activity against many of the anaerobic microbes associated with the various periodontal diseases. Following absorption, tetracycline HCl is released at bacteriostatic concentrations. Further, tetracycline HCl has been shown in various in vitro and in vivo studies to etch and/or remove the root surface smear layer and cause surface demineralization, to delay pellicle and plaque formation and to exhibit anti-collagenase activity. [11]

Citric acid combined with scaling and root planning would significantly reduce pathogenic bacteria of the periodontal pocket when compared to scaling and root planning alone (SRP). [12] The use of citric acid in the treatment of periodontal diseases favors the repair of periodontal lesions and prevents the appearance of long junctional epithelial attachments. Citric acid does not have deleterious effects after direct application to normal periodontal connective tissues. Root conditioning with citric acid has been shown to remove endotoxin from the root surface and has an antibacterial effect on microbiological plaque in vitro. [13]

With the development of local drug delivery systems for placement into the periodontal pocket, clinical studies which compare its efficacy are needed to determine their potential in therapy. [14]

The objective of this study is to evaluate the clinical and microbiological effects of each of four periodontal therapies, in the management of periodontal pockets at previously untreated single-rooted teeth, namely, root planning alone (RP), tetracycline-containing gel alone (TCG group), root planning plus tetracycline-containing gel (RP + TCG group), and root planning plus a mixture of tetracycline and citric acid-containing gel (RP + TC-CAG group).


   Materials and Methods Top


Subjects

Four anterior teeths from four quadrants with a probing depth of 4-6 mm, in each of 20 subjects with chronic periodontitis, were selected for the study from the Department of Periodontics, Meenakshi Ammal Dental College and Hospital, Chennai, after getting approval from ethical committee. Each of the four teeth from four quadrants was subjected to four different treatment modalities in the same subject.

Inclusion criteria are as follows:

  • Patients who have at least four anterior teeth in four quadrants with probing depth of 4-6 mm.
  • Teeth selected should be vital.
  • Patients who have an ability to maintain optimum oral hygiene after the initial phase of treatment.
Exclusion criteria are as follows:

  • Patients who have undergone antibiotic therapy and periodontal therapy in the previous 3 months.
  • Patients who have a history of allergy or adverse reaction to tetracycline.
  • Patients suffering from any systemic disease.
  • Pregnant and lactating females.
Clinical protocol

All the subjects, selected in this study received supragingival scaling and were given oral hygiene instruction prior to the commencement of the study as well as throughout the study. The subjects were then advised to report after 2 weeks.

A total of 80 teeth were divided into four groups of 20 teeth each, on the basis of one of the following four treatments:

Group 1: Root planning alone (RP group)

Group 2: Tetracycline-containing gel alone (TCG group)

Group 3: Root planning plus tetracycline-containing gel (RP + TCG group)

Group 4: Root planning plus a mixture of tetracycline and citric acid-containing gel (RP + TC-CAG group)

Preparation of gels ( Tetracycline and Tetracycline-citric acid gel )

The constituents of tetracycline-containing indigenously prepared gel were poloxamer, tetracycline-HCl, and distilled water. The composition of the mixture was ethanol, citric acid, carbopol, tetracycline-HCl, and distilled water. Carbopol was used as the gelating agent. The tetracycline concentration in both gels was 5%. The citric acid concentration was 33%. The pH of tetracycline containing gel was 3.0-3.1, and tetracycline and citric acid-containing gel was 1.1-1.2.

The following clinical parameters were recorded on 0 day:

  • Plaque index (PI) (Silness. J and Loe. H)
  • Sulcular Bleeding Index (Muhlemann and Son)
  • Probing pocket depth
  • Clinical Attachment level
Subgingival plaque samples from each site were collected with sterile No. 1/2 Gracey curette and transferred to a Neubar counting chamber. It was then examined under the dark field microscope at a magnification of ×400 to determine percentage of motile rods and spirochetes were determined in randomly selected microscopic fields by dark field microscope.

All the teeth except those in the TCG group received a thorough root planning [Figure 1], and then tetracycline-containing gel [Figure 2] and a mixture of tetracycline and citric acid containing gel [Figure 3] was applied to RP + TCG group and RP + TC-CAG group [Figure 4], respectively.
Figure 1: Group I - Root planing

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Figure 2: Group II - Tetracycline-containing gel application

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Figure 3: Group III - Root planing + Tetracycline-containing gel application

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Figure 4: Group IV - Root planing + Tetracycline and citric acid gel application

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The gel was applied to the bottom of the pocket using a syringe tipped with a 23 gauge needle. Using a small burnisher, root surface was burnished for 5 min to condition it with these gels. The area was then, irrigated for 3 min with physiologic saline to clean the excess gel.

Clinical parameters were recorded at 8 th and 12 th week. Subgingival plaque samples were also collected from each site on 8 th and 12 th week.

Statistical analysis

The clinical parameters and microbiological analysis of the four groups done on 0 day, 8 th week and 12 th week were compared statistically. Wilcoxon signed rank test, Mann − Whitney U-test and Kruskal − Wallis one-way ANOVA test were employed to test the significance of mean differences between baseline and 8 th week, baseline and 12 th week, and 8 th week and 12 th week.


   Results Top


The mean values for PI are presented in [Table 1]. In all groups, regardless of treatment methods, significant reduction in PI scores was observed in the 8 th week, and this reduction was maintained throughout the experimental period. The reduction was statistically significant only between Group II and Group IV (P = 0.001). [Table 2] represents the sulcular bleeding index (SBI) score. The SBI score showed significant reduction at 8 th and 12 th week, respectively, in all the treatment groups, compared to baseline value. The greatest reduction in SBI score was observed for Group I. On comparing the mean SBI score, only between Group I and Group III, the reduction was found to be statistically significant. The probing depths are shown in [Table 3]. The initial mean probing pocket depths were 5.8 ± 0.6 mm, 5.6 ± 0.6 mm, 5.7 ± 0.6 mm, and 5.6 ± 0.6 mm for Group I, Group II, Group III, and Group IV, respectively, and there was no significant difference among these initial values. All the treatment groups exhibited a significant reduction in probing depths throughout the study, compared to baseline values. When all the four groups were compared, there was a statistically significant difference between Group IV and Group I (P < 0.0001). Group IV showed a higher reduction in probing pocket depth when compared to Group I. The clinical attachment level for each group at each time-period is represented in [Table 4]. The mean change in clinical attachment level from 0 day to 12 th week for Group I was 2.0 ± 1.1 mm, Group II it was 1.9 ± 0.8 mm, Group III was 2.8 ± 1.6 mm, Group IV was 3.8 ± 1.6 mm. At the end of the study when the mean change in the clinical attachment level was compared, the gain was statistically significant between Group I and Group IV, and between Group II and Group IV (P < 0.0001).
Table 1: Plaque index (mean±S.D.)


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Table 2: Sulcular bleeding index (mean±S.D.)


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Table 3: Probing pocket depth (mean±S.D. in mm)

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Table 4: Clinical attachment level (mean±S.D. in mm)

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Bacterial morphotypes

The percentage of motile rods and spirochetes of the four experimental groups was compared prior to the treatment. Shifts after the treatment are shown in [Table 5]. Treatment resulted in a significant decrease in spirochetes for all groups. At baseline all the four groups showed similar count [Figure 5], [Figure 6], [Figure 7] and [Figure 8]. At the end of the study when the mean change in the count of rods was compared, the reduction was statistically significant between Group I [Figure 9] and [Figure 10] and Group III [Figure 11] and IV [Figure 12] and [Figure 13], between Group II [Figure 14] and Group III and IV and also between Group III and Group IV (P < 0.0001). However, the change was not statistically significant, when the mean change in the count of spirochetes was compared.
Figure 5: Microbiological analysis of group I - Day 0

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Figure 6: Microbiological analysis of group II - Day 0

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Figure 7: Microbiological analysis of group III - Day 0

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Figure 8: Microbiological analysis of group IV - Day 0

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Figure 9: 8th week

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Figure 10: 12th week

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Figure 11: 12th week

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Figure 12: 8th week

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Figure 13: 12th week

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Figure 14: 12th week

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Table 5: Bacterial morphotypes (mean±S.D.)

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   Discussion Top


The purpose of this study was to investigate the clinical and microbiological effects of four treatment modalities on one anterior tooth in each quadrant, with 4-6 mm probing pocket depth.

Regardless of treatment methods, significant reduction in the PI score was observed in all the groups. When all the four groups were compared statistically, Group IV showed a higher change in the PI score (1.07 ± 0.35), when compared to Group II (0.60 ± 0.26).

Application of tetracycline has some adjunctive effects upon the inflammation in the surrounding soft tissues. This effect is probably mediated indirectly, through the effect upon the bacteria, as well as by a direct anti-inflammatory effect. [15] It is reasonable to assume that a 5-min application of citric acid could entirely eliminate the bacteria and any subclinical amounts of retained calculus from scaled and planed roots. These may be the benefits of adding citric acid. [12] This combination using both tetracycline and citric acid, along with scaling and root planning has shown beneficial effects. This is in accordance to the studies done by Koji et al. [12] and Lie et al. [15]

There was a reduction in the bleeding scores throughout the present study. The decrease in the bleeding scores in all the four groups may be attributed to the resolution of marginal inflammation. Despite the beneficial effects of tetracycline, change in the bleeding scores of Group III was less significant to Group I. The greater mean change in Group I could be due to its higher baseline value, when compared to other groups. The decreased change in the bleeding scores of Group III could be due to the mechanical interference of tetracycline when applied into the periodontal pocket immediately following scaling. This mechanical disruption of the periodontal tissues may have compromised the local host defense system. Although delayed, the final attachment gain was equal to that of other treatment modalities. [16]

In the present study, Group IV did not show a significant change in bleeding scores, despite a higher reduction in bacterial morphotypes. This could be due to the irritating effect of low pH citric acid on gingival connective tissue, which temporarily delayed healing. [13]

In the present study, the reduction in probing depth and gain in clinical attachment level were significant in all treatment groups. Group IV (2.9 ± 0.6 mm) showed a higher reduction in probing pocket depth when compared to Group I (1.9 ± 0.6 mm), and a higher gain in clinical attachment level when compared to Group I (2.0 ± 1.1 mm) and Group II (1.9 ± 0.8 mm).

In Group IV, the dentin conditioning by citric acid and tetracycline enhanced the reattachment, thus favoring faster periodontal healing. This combination therapy may have influenced the behavior of periodontal fibroblasts by improving their attachment and spreading over the root surfaces. [17] The smear layer formed during scaling and root planning due to an incomplete removal and translocation of dentin by instrumentation, is removed or diminished by citric acid or tetracycline-HCl treatment. The disappearance of the smear layer is to be regarded as a secondary beneficial effect of applying these agents to root surfaces following instrumentation. [18] These results were similar to that seen in the study done by Vanheusden et al. [17] and Jeong et al. [18]

In the present study, Group III showed greater reduction in probing pocket depth and gain in the clinical attachment level than Group I and Group II. There appears to be a direct effect related to the use of tetracycline at numerous sites. Diffusion of tetracycline into the saliva could beneficially affect healing by reducing the probability of exogenous reinfection during the crucial healing period following scaling and root planning, and tetracycline-containing gel. [19] Direct blocking of matrix metaloproteinase could be another factor responsible for the improvement. [20]

This was similar to many other study results. Pavia et al. [21] observed a significant mean reduction in pocket depth and gain in clinical attachment level for the combined tetracycline and scaling and root planning. Tetracycline alone did not perform better than scaling and root planning. Newman et al. [22] compared two treatments modalities (scaling and root planning alone and scaling and root planning plus tetracycline therapy) and demonstrated that probing pocket depth reduction was statistically greater at 1, 3, and 6 months for tetracycline treated sites. At 1 and 3 months, both conventional therapy and tetracycline application alone provided the same degree of improvement in attachment level. Goodson et al. [16] demonstrated significant probing depth reductions and attachment level gains up to 12 months after tetracycline treatment, alone or preceded by scaling. Greenstein [14] observed that in probing pocket depth of 4-6 mm, scaling, and root planning alone showed pocket depth reduction of 1.29 mm and clinical attachment gain of 0.55 mm. However, tetracycline therapy and scaling and root planning showed a pocket depth reduction of 1.0 mm and clinical attachment gain of 1.1 mm.

Spirochetes and motile rods in subgingival microflora are frequently used as an indicator for monitoring the efficacy of a periodontal therapy or for estimating risk for disease progression. Therefore, it seems reasonable to use them as indicators for evaluating effects of topical application of tetracycline-containing gels. [18]

In the present study, the reduction in the mean change in count of rods was statistically significant between Group I and Group III and IV, between Group II and Group III and IV and also between Group III and Group IV. The mean change in count of spirochetes was not statistically significant.

Motile rods and spirochetes decreased as a result of all four therapies. The tetracycline and citric acid-containing gel acted as both an antimicrobial and root-conditioning agent. This was in accordance to the study done by Jeong et al. [18] In their 12-week study, a significant decrease in the proportion of motile rods was found primarily in RP + TC-CAG and a significant decrease in the proportion of spirochetes in all groups. In the present study, Group III showed decrease in the proportion of motile rods than Group I and Group II. The effects of tetracycline on the microflora or gingival inflammation are not unexpected from a broad-spectrum antibiotic. Silverstein et al. [23] observed a statistically significant decrease from baseline values in the tetracycline group and scaling and root planning group for the percentage of motile rods and spirochetes at eight weeks. Listgarten et al. [24] reported that in scaling with tetracycline-treated patients, there was a trend for the motile rods and spirochetes to be at lower levels. Goodson et al. [20] showed that at tetracycline-treated sites, total counts of spirochetes, motile rods, and nonmotile rods were significantly reduced immediately following the treatment. In comparison, scaling produced much smaller alterations of dark-field counts.

A tetracycline-containing gel showed marked effect primarily on subgingival microflora. A mixture of tetracycline and citric acid-containing gel resulted in marked improvement primarily in probing depth and to some degree in the attachment level. This difference may be attributed to different modes of action of two gels; that is, the former acted as a conventional antimicrobial agent, while the latter acted as both an antimicrobial and root-conditioning agent. In consideration of the concentration, diluting factor by gingival crevicular fluid, pH, and duration within pocket, the root-conditioning effect of a tetracycline-containing gel seemed to fall short of expectation. [18]

The limitations of this study were its sample size (N = 20), short shelf-life (48 h) of the tetracycline and citric acid-containing gel and short observation period. Another limitation was that the bacterial morphotypes studied, included only motile rods and spirochetes. The preparation of the TC-CAG should be improved, so as to have a longer shelf-life. Further studies are needed to verify the long-term effects of these gels on the periodontium, to determine the most appropriate concentration of gels, the frequency and interval of reconditioning, and to detect side effects of these therapies.


   Conclusion Top


The root-conditioning potential was significantly augmented by combining the tetracycline with a citric acid-containing gel. A single application of a tetracycline-containing gel produced long-term improvement in gingival health, lasting for 8-12 weeks. Although tetracycline has a lower demineralizing effect than citric acid, it has many other advantageous properties. Hence, in this study, the combined gel of tetracycline and citric acid has shown a synergistic effect of the two agents and a more powerful demineralizing potential than tetracycline-containing gel. [18]

 
   References Top

1.Larjava H, Salonen J, Hakkinen L, Narhi T. Gingival epithelium on root surfaces in vitro. J Periodontol 1997;45:345-50.  Back to cited text no. 1
    
2.Forgas LB, Gound S. The effects of antiformin-citric acid chemical curettage on the microbial flora of the periodontal pocket. J Periodontology 1987;65:153-8.  Back to cited text no. 2
    
3.Genco RJ. Antibiotics in the treatment of human periodontal diseases. J Periodontol 1981;33:545-58.  Back to cited text no. 3
    
4.Adriaens P, Adriaens L. Effects of non-surgical therapy on hard and soft tissues. Periodontology 2000 2004;36:121-45.  Back to cited text no. 4
    
5.Minabe M, Takeuchi K, Tamura T, Hori T, Umemoto T. Subgingival administration of tetracycline on a collagen film. J Periodontol 1989;60:552-7.  Back to cited text no. 5
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6.Novak MJ, Dawson DR, Magnusson I, Karpinia K, Polson A, Polson A, et al. Combining host modulation and topical antimicrobial therapy in the management of moderate and severe periodontitis: A randomized multicenter trial. J Periodontol 2008;79:33-41.  Back to cited text no. 6
    
7.Register AA. Bone and cementum induction by dentin, demineralized in situ. J Periodontol 1973;44:49-54.  Back to cited text no. 7
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8.Register AA, Burdick FA. Accelerated reattachment with cementogenesis to dentin, demineralized in situ. Defect in repair. J Periodontol 1975;47:497-505.  Back to cited text no. 8
    
9.Babay N. Attachment of human gingival fibroblasts to periodontally involved root surface following scaling and/or etching procedures: A scanning electron microscopy study. Braz Dent J 2001;12:17-21.  Back to cited text no. 9
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10.Bernard SM, Tannenbaum P. Enhanced repair and regeneration of periodontal lesions in tetracycline-treated patients: Case Reports. J Periodontol 1991;62:341-50.  Back to cited text no. 10
    
11.Connie LD, Charles MC, William JK, Michalowicz BS, Philstrom BL, Roxanne AL, et al. Evaluation of periodontal treatments using controlled-release tetracycline fibers: Clinical response. J Periodontol 1995;66:692-9.  Back to cited text no. 11
    
12.Koji T, Timoty J, Abdel H. The effect of citric acid on retained plaque and calculus. J Periodontol 1989;60:81-3.  Back to cited text no. 12
    
13.Valenza V, D'Angelo M, Farina-Lipari E, Farina F, Margiotta V. Effects of citric acid on human gingival epithelium. J Periodontol 1987;54:794-5.  Back to cited text no. 13
    
14.Greenstein G. Local drug delivery in the treatment of periodontal disease: Assessing the clinical significance of the results. J Periodontol 2006;77:565-78.  Back to cited text no. 14
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15.Lie T, Bruun G, Olav EB. Effects of topical metronidazole and tetracycline in treatment of adult periodontitis. J Periodontol 1998;61:819-27.  Back to cited text no. 15
    
16.Goodson JM, Hogan PE, Dunham SL. Clinical responses following periodontal treatment by local drug delivery. J Periodontol 1985;56:81-7.  Back to cited text no. 16
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17.Vanheusden AJ, Goffinet G, Zahedi S, Nusgens B, Lapiere CM, Rompen EH. In vitro stimulation of human gingival epithelial cell attachment to dentin by surface conditioning. J Periodontol 1999;70:594-603.  Back to cited text no. 17
    
18.Jeong SN, Han SB, Lee SW, Magnusson I. Effects of tetracycline-containing gel and a mixture of tetracycline and citric acid-containing gel on non-surgical periodontal therapy. J Periodontol 1994;65:840-7.  Back to cited text no. 18
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19.Connie LD, Charles MC, William JK, Michalowicz BS, Philstrom BL, Roxanne AL, et al. Evaluation of periodontal treatments using controlled-release tetracycline fibers: Maintenance response. J Periodontol 1995;66:708-15.  Back to cited text no. 19
    
20.Goodson JM, Offenbacher S, Farr DH, Hogan PE. Periodontal disease treatment by local drug delivery. J Periodontol 1985;56:265-72.  Back to cited text no. 20
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21.Pavia M, Nobile CG, Angelillo IF. Meta-Analysis of local tetracycline in treating chronic periodontitis. J Periodontol 2003;74:916-32.  Back to cited text no. 21
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22.Newman MG, Kornman KS, Doherty FM. A 6-month multi-centre evaluation of adjunctive tetracycline fiber therapy used in conjunction with scaling and root planning in maintenance patients: Clinical results. J Periodontol 1994;65:685-91.  Back to cited text no. 22
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23.Silverstein L, Bissada N, Manouchehr-Pour, Greenwell H. Clinical and microbiologic effects of local tetracycline irrigation on periodontitis. J Periodontology 1988;67:301-5.  Back to cited text no. 23
    
24.Listgarten MA, Lindhe J, Hellden LB. Use of tetracycline and/or scaling on human periodontal disease. Clinical, microbiological and histological observations. J Clin Periodontol 1978;5:246-71.  Back to cited text no. 24
    

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Correspondence Address:
Renny Paul George
Department of Periodontics and Implantology, Meenakshi Ammal Dental College, Chennai, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-9290.114949

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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]

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