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Aim: To follow changes (over 2 years) in subgingival bacterial counts of five microbial complexes including health-related Actinomyces spp. Results: We observed short-term beneficial changes in the composition of the red complex of up to 3 months by treating subjects with AMOX+MET+TET.
Conclusions: Although short-term reductions in the counts of the red complex were observed in sites that were treated with AMOX+MET+TET, long-term significant effects were not observed with any of the eight treatments.
To access the supplementary material for this article, please see Supplementary Files under Article Tools online.
In a previous 2-year study on the clinical effects of periodontal treatments (1), we found that combining periodontal surgery (SURG) with systemic amoxicillin (AMOX) and systemic metronidazole (MET), and locally delivered tetracycline (TET) produced significant clinical improvement of chronic periodontitis.
Studies have demonstrated that five different clusters or communities of bacteria may be found in subgingival plaque of subjects with chronic periodontitis.
Systemic or locally applied antibiotics have been used for years in the treatment of periodontitis. Control of periodontal disease may best be obtained by eliminating or suppressing the causative organisms and by establishing a host-compatible microbiota. The microbiological data were collected from 217 subjects with chronic periodontitis at two different periodontal centres in Boston, USA and Göteborg, Sweden (22). The subgingival plaque was sampled separately, after first removing supragingival plaque, from each site with individual sterile Gracey curettes and assessed for the contents of 40 subgingival bacterial species using checkerboard DNA–DNA hybridizations (21). The response variables were counts of Actinomyces and counts of the red, orange, yellow, green, and purple complexes (2). The distributional problems discussed above have led to development of more general count models, which allow for the modelling of a wide range of count response situations. Modelling bacterial count data is often challenging due to disproportionately high numbers of zeros in the response variable. Generalized estimating equations (GEE) (26) is one of the most widely used statistical methods in the analysis of longitudinal data (27).
The Akaike information criterion (AIC) (29), which is normally used for GLM model selection is not applicable with GEE models.
Fractional response variables are encountered in many areas of research including biological settings.
As shown in Table 1, there were no significant baseline differences between subjects in the control group (SRP) and those receiving other treatments. There were no significant baseline differences between patients who were in the control group (SRP) and those receiving other treatments as evidenced by the large p-values. There were no significant changes in counts of Actinomyces that were observed in all treatment groups compared to counts in the reference group, SRP. To assist in the interpretation of the results, part (a) in each table reports changes in counts from 3 months for the reference group (SRP) after adjusting for baseline counts.
We observed a 3-month significant reduction in changes of the red complex counts from baseline of 37% in subjects treated with AMOX+MET+TET compared to SRP-treated subjects.
Finally, we tested the joint significance of treatment and time (and the interaction) to see whether there were any treatment effects.
From the computed IRR and their confidence intervals for sites with severe chronic periodontitis in Table 2, we did not observe significant changes in counts of Actinomyces. Box-plot showing the median distribution of Actinomyces counts by treatment group at baseline. Box-plot showing the median distribution of the red complex counts by treatment at baseline. Figure 5 shows that there were minimal variations in the median distributions of the orange complex counts at baseline while Fig. Box-plot showing the median distribution of orange complex counts by treatment at baseline. Changes in natural log counts of the orange complex at each study time point from baseline. There were no significant reductions in orange complex counts that were observed in all treatment groups compared to SRP. There were minimal variations in the median distributions of the purple complex counts at baseline as shown in the box-plots of Fig. We also tested the effects of gender, smoking habits, nationality, age, PD, accumulation of plaque, BOP, gingival redness, and CAL as predictors of counts of the complexes over time.
We did not observe significant differences in counts of the complexes and Actinomyces between males and females in sites that had an initial PD of at least 5 mm and then treated, as shown in Table S4. As with count models, we tested the joint significance of treatment and time (and the interaction) to see the extent in which the treatments influenced the composition of the bacteria. Knowledge suggesting that periodontal pathogens operate in complexes rather than as single pathogens has led to changes in treatment approaches to be considered.
Although short-term improvements in the counts of the red complex were observed in sites that were treated with AMOX+MET+TET, long-term significant effects were not observed with any of the eight study treatments.
In chronic periodontitis, we desire treatments that elevate Actinomyces counts because maintaining a bacterial flora associated with health after treatment is crucial for the prognosis. For many years, the American Heart Association (AHA) recommended that patients with heart conditions take antibiotics prior to just about any dental procedure. In 2007, however, the AHA updated its recommendations, saying that many patients who would have previously been recommended to take antibiotics no longer need to and there is little proof that the preventative antibiotics did what they were supposed to do. Bottom line: your dentist will prescribe an antibiotic prior to your surgical procedure if appropriate, but you may not need it. What about antibiotics for an infection that is unrelated to your dental surgery, such as a sinus infection or an ear infection? Request Appointment Send us a request and our staff will get back to you shortly. Persons using assistive technology might not be able to fully access information in this file. America Conference, and serving on the Mycology Research Laboratories scientific advisory board. These guidelines were developed by a panel of specialists from the United States government and academic institutions.
ART drugs, leading to subtherapeutic serum levels and the development of antiretroviral drug resistance. OIs that occur after patients have been started on ART can be categorized into three groups. Physiologic changes during pregnancy can complicate the recognition of OIs and complicate pharmacokinetics. Increased cardiac output by 30%--50% with concomitant increase in glomerular filtration rate and renal clearance. Increased plasma volume by 45%--50% while red cell mass increases only by 20%--30%, leading to dilutional anemia. Young children with cryptosporidial diarrhea might infect adults during diapering and cleaning after defecation. Among persons with profuse diarrheal illness, a single stool specimen is usually adequate for diagnosis. Similar short-term improvements with the same treatment were observed for Tannerella forsythia and Treponema denticola of the red complex. Poor oral hygiene in patients with severe chronic periodontitis diminished the beneficial effects of treatment. It was concluded that both surgical and non-surgical therapies can be used to arrest chronic periodontitis.
The red complex consisting of Tannerella forsythia, Porphyromonas gingivalis, and Treponema denticola is frequently found in deeper periodontal pockets and its presence is usually preceded by species of the more diverse orange complex. The idea of using antibiotics in the treatment is that they should lead to beneficial changes in the composition of the subgingival microbiota by reducing pathogens and allowing the growth of host-compatible species (3). Most studies have been too short to demonstrate this and beneficial species have rarely been examined. For details concerning patients, inclusion and exclusion criteria, periodontal treatments and clinical monitoring Goodson et al.
A unique feature of this distribution is that its mean is equal to its variance, a relationship called equidispersion.
It is derived as a Poisson–gamma mixture distribution and is basically an extension of the Poisson model with an additional ancillary or heterogeneity parameter. In addition to this Poisson violation, our data were structured in panels, with repeated observations per tooth and teeth nested within patients. It is an extension of the generalized linear model (GLM) (28) to account for possible correlations between the repeated measurements of an individual over time. As data on proportions are bounded between 0 and 1, the use of standard linear models becomes less appealing. To reduce the multiple testing problems, we used a significance level of 1%, and correspondingly, we computed 99% confidence intervals in our tables. Box-plots for the mean distribution of the natural log counts of Actinomyces and red, orange, yellow, purple, and green complexes are given in Figs.

The IRR in part (c) of each table represents the change in counts at a certain time point for each treatment group relative to the change in the reference group (SRP).
For example, in Table 3, counts of the red complex significantly increased by 77% after 24 months.
No other significant reductions of the red complex counts in sites with severe chronic periodontitis were observed from all study treatments compared to SRP-treated subjects.
In all treatment groups, there was very little variation in the median distribution of Actinomyces counts at baseline. Study time points 1–6 correspond to baseline, 3, 6, 12, 18, and 24 months, respectively. 6 shows that compared to SRP, counts in the other treatment groups were higher between 12 and 24 months.
Red and orange complexes’ counts significantly increased in smokers by 18% and 8%, respectively. Although the overall tests were not significant, we observed findings that were comparatively similar to the count responses. This study examined over 2 years the effect of different periodontal therapies, including combinations of therapies on different bacterial species of the subgingival microbiota present in five different complexes (2) with the aim of selecting the most beneficial periodontal therapy. We also examined the effect of BOP, accumulation of plaque, deeper pockets, and smoking on counts of the complexes. However, we did not find evidence that the periodontal treatments promoted growth of Actinomyces in severely affected sites. However, due to extra variability in our bacterial data, a suitable model for overcoming the problem of over-dispersion and correlated observations was the negative binomial generalized estimating equation (NB GEE) model. For most patients, the risks of taking such preventative antibiotics outweigh the benefits. If you have congenital heart disease or another heart issue, talk with your dentist and cardiologist about what they recommend.
If you’re currently taking antibiotics, it’s fine for you to keep taking them—as long as your doctor and dentist are aware.
Make sure your doctor, dentist, and oral surgeon are aware of all medications you are taking so that they can ensure you’re taking a safe combination.
With all patients, we’ll go over standard procedures, including antibiotics, to make the entire process as comfortable as possible, whether your procedure is minor or major.
However, IRIS has occurred weeks after ART was started and in sequestered sites such as bone.
The tidal volume increase of 30%--40% should be considered if ventilatory assistance is required. Methylprednisolone at 75% of the respective prednisone dose can be used if parenteral administration is necessary. Certain clinicians prefer IV pentamidine because of convincing data regarding its high degree of efficacy.
Failure attributed to lack of drug efficacy occurs in approximately 10% of those with mild-to-moderate disease. The absence of IgG antibody makes a diagnosis of toxoplasmosis unlikely but not impossible. Person-to-person transmission is common, especially among sexually active men who have sex with men (MSM). Nationally distributed brands of bottled or canned carbonated soft drinks are safe to drink.
Subgingival plaque was collected mesiobuccally from each tooth, except third molars, from 176 subjects, completing the study, at baseline, 3, 6, 12, 18, and 24 months post-treatment and analysed for 40 different bacteria using checkerboard hybridization. Previous studies have shown that systemic treatment with MET, which act against anaerobic bacteria, has beneficial effects on the subgingival microbiota of periodontal diseases (4). The number of species studied has also tended to be too limited to monitor the effect of treatment on both putative periodontal pathogens and host-compatible species. We considered data from 1,463 teeth with an initial PD of at least 5 mm from 176 subjects who completed the study, giving an average of 8.3 teeth per subject.
We evaluated the long-term benefits of the therapies either individually or as combinations.
Several distinct NB models have been developed to account for distributional problems associated with count data (23).
Zero-inflated count models, which were first introduced by Lambert (25), have the capacity to handle excessive zero counts. GEE, which is a population averaging panel method, accounts for the correlation between observations in GLM by introducing a working correlation matrix and by using robust variance estimators. Pan (31) proposed the quasi-likelihood under the independence model criterion (QIC) for selecting the best model in GEE analyses. We used the logistic model with GEE to handle the dependence in the data in the same way as described above for the analysis of counts. However, results that are significant at 5% level are also indicated, by a single asterisk. Hence, the IRR conveys information on relative differences in changes from 3 months, and not on absolute values. Part (b) shows the IRR for changes in counts at 3 months from baseline compared to the reference group, SRP. Because of these differences, we shall proceed and report below the developments in treatment effects that were observed over time. The IRR for the red complex counts in sites that had an initial PD of at least 5 mm and had been treated with AMOX+MET+TET was 0.63 after 3 months as shown in Table 3 (see also Fig. Much lesser counts of the red complex were observed between baseline and 3 months in subjects who were treated with AMOX+MET+TET. However, there were no significant beneficial changes in counts of the orange complex that were observed over time as shown in Table 4. For example, in Table S5 (baseline covariates not presented), we observed a short-term benefit of using AMOX+MET+TET.
We specifically looked at changes that occur in severely affected mesiobuccal sites (PD≥5 mm). We believe that these four factors were most important for diminishing the effects of the study treatments. Although SURG has long been suspected of initiating loss of CAL through a detrimental effect on osteoblasts, it remains a useful procedure for effective removal of plaque and elimination of periodontal pockets.
Because certain procedures, such as a tooth extraction or a root canal, can allow bacteria into the bloodstream. This is especially important for patients who might also require preventative antibiotics, as the American Dental Association says that these patients would need an antibiotic from a different class than the one the patient is already taking.
A negative binomial (NB) generalized estimating equation (NB GEE) model was used to analyze count data and a logistic GEE was used for proportions.
No periodontal treatments applied to severely affected sites promoted the growth of Actinomyces.
Site-level effects such as bleeding on probing (BOP), accumulation of plaque, gingival redness, and suppuration were significant predictors of further loss of clinical attachment level (CAL) and increased pocket depth (PD). In contrast, species of the yellow, green, and purple complexes are considered to be host compatible and are generally associated with healthy sites. Fluctuation or at least quantitative changes in the incidence of potential periodontal pathogens were reported after administration of MET (5).
Rather than concentrating on specific organisms, recent research has indicated that examination of bacterial complexes may be more useful for addressing the question of periodontal pathogenesis and the effects of therapy.
The chemiluminescence signals from each membrane were read using a Lumilmager Workstation (Boehringer-Mannheim, Mannheim, Germany) and evaluated by comparing the signals obtained with those of pooled standard samples containing 106 and 105 bacteria of each of the 40 bacterial species. In most cases, data are over-dispersed, that is, the variance is greater in value than the mean. These models include the zero-inflated Poisson (ZIP), which is a subset of the zero-inflated negative binomial (ZINB).
The method differs from a random effects model, which is subject-specific, by averaging the model effects across individuals. If the IRR is significantly less than 1, then the treatment group has experienced a relative decrease of bacterial counts compared with the development in the reference group, SRP. For example, in Table 3 changes from baseline were significantly lower by 37% in subjects who were treated with AMOX+MET+TET compared to subjects treated with SRP.
For example, there was a sharp decrease in Actinomyces counts between baseline and 3 months in the AMOX+MET+TET and TET treatment groups.
Compared to the reference group SRP, subjects in the AMOX+MET+TET and TET groups had lesser counts between baseline and 3 months. S2, decreases in counts of the purple complex were observed between baseline and 3 months in all treatments except in the SURG-treated group. Count levels of the orange and green complexes were significantly lower in Swedish subjects while Actinomyces counts were significantly higher compared to American subjects. However, just like the analysis of the count data, there were no significant benefits that were observed with the other treatments.

Taking samples from all sites might have given a better view of the total cultivable microbiota.
For example, about 41% of our study subjects were current smokers and our study revealed that colonization of sites by periodontal pathogens was more extensive in smokers than in non-smokers. However, the problems that were observed and discussed above could have also played a major role in diminishing the effectiveness of SURG. For those who are susceptible, dental professionals commonly prescribed antibiotics to prevent life-threatening infection—called infective endocarditis. Smoking elevated counts of both the red and orange complex while bleeding on probing (BOP) and gingival redness were also predictors of more red complex counts. MET has also been compared directly to other antibacterial substances in the treatment of periodontitis. By using checkerboard DNA–DNA hybridization (21), the presence and levels of 40 cultivable periodontal species with a putative pathogenic or a host-compatible role were followed for 2 years in this study.
The probes used had been tested for specificity and cross-hybridization, as described previously (21). In brief, exclusion criteria were known allergies to the antibiotics being used, antibiotic or periodontal treatment within the last 3 months, pregnancy, nursing, or systemic conditions that would influence the course of periodontal treatment, or allergy to AMOX, MET, TET, lidocaine, or chlorhexidine. The only drawback with these models is their limited abilities to handle nested or clustered data from longitudinal studies. The benefit of the GEE approach is that the correlation matrix can be arbitrarily parameterized.
While the logistic GEE model looks at the extent to which the treatments influenced the total composition of the bacteria, the GEE for counts looked at the extent to which the treatments influenced the different levels of the bacteria complexes. Conversely, if the IRR is significantly larger than 1, then the treatment group has experienced a relative increase of bacterial counts relative to the development in the reference group. All other things being equal and compared to SRP, this indicates that subjects who were treated with AMOX+MET+TET had changes in counts of the red complex significantly reduced from baseline by 37% after 3 months. At the 5% significance level, sites that were treated with SURG+AMOX+MET had an increase in counts of the yellow complex of 85% and 70% after 18 and 24 months, respectively, compared to SRP-treated subjects as shown in Table S1.
However, there were no significant changes in counts of the purple complex that were observed in all treatment groups as shown in Table S2. Further increase in PD significantly elevated counts of the red and orange complexes by 6% and 3% respectively. The analysis of proportions also showed that smoking increased the odds of the red complex by 22%, deeper pockets increased the odds of the red complex by 7%, the odds of the red complex was 4% higher in subjects who had experienced further losses in clinical attachment, and gingival redness and BOP increased the odds of the red complex by 10% and 8%, respectively. However, we know from previous work that the red and orange complexes are the ones most related to clinical disease, particularly in terms of PD.
This may explain why smokers are less responsive to periodontal therapies than non-smokers. Comparatively similar findings were obtained by analyzing counts and by analyzing proportions.
All such treatments, including MET, azithromycin, sub-antimicrobial doses of doxycycline, and scaling and root planing (SRP), reduced counts of red complex species at 12 months but no significant differences were detected among treatment groups for most species (6). Species defined under each of the five bacterial complexes in subgingival plaque (2) were assessed before and after different treatments.
Both males and females of all races who were at least 20 years of age, had at least 15 natural teeth, and were in good general health were included in the study. Yet another assumption behind the Poisson regression model is the requirement that counts are independent of one another.
Both models can be extended and modified to accommodate any extra correlation in the data that violate distributional properties of these models. The following correlation structures were considered for our data; independence, exchangeable, unstructured, autoregressive, stationary, and non-stationary. Then, under the exchangeable correlation structure, the model with the smallest QIC value among the different models fitted with this working correlation was considered to be the best GEE model. In the case of the red and orange complexes, the treatment is considered to be effective compared with SRP when the IRR is significantly less than 1. Counts of the red complex were also higher in sites that were bleeding, lost more attachment, and had gingival redness. In the analysis of red counts (Table 3), smoking, deeper pockets, further losses in attachment, gingival redness, and BOP elevated the red counts by 18%, 6%, 3%, 12%, and 10%, respectively.
In addition, selected Actinomyces species, thought to be associated with periodontal health were monitored. The exchangeable correlation structure, which had the smallest quasi-likelihood independence criterion (QIC), was chosen.
In contrast, higher counts of Actinomyces, which is associated with periodontal health, are desirable. S2A, minimal variations in the median distributions of the green complex counts were also observed as shown in Fig. Systemic use of doxycycline or MET+AMOX led to levels of Aggregatibacter actinomycetemcomitans below detection limits in localized juvenile periodontitis at 10, 30, and 90 days post-treatment (9). At baseline, all subjects received SRP performed under local anaesthesia and usually finished in four weekly visits. Observations within panels cannot be considered to be independent but may be highly correlated. This structure assumes that the correlations between all observations within a panel are the same. In this case, the treatment is considered effective compared with SRP when the IRR is significantly more than 1. SRP was performed by treating a quadrant at a time under local anaesthesia at approximately weekly intervals.
In addition, we had measurements from several teeth per patient, giving rise to another level of dependence.
This implies that any correlation value within the structure may be exchanged with any other.
For example, in Table 2 Actinomyces counts were 1.28 times higher at 6 months in subjects who were treated with AMOX+MET+TET compared to subjects who were treated with SRP. Figure S3 shows that compared to SRP, much lesser counts of the green complex were observed at 3 months in the TET and AMOX+MET+TET-treated groups. However, as stated by Zeger and Liang (26), the GEE approach is very attractive because estimates from the GEE method are asymptotically consistent even if the correlation structure has been misspecified. As demonstrated in Table S3, we observed a 42% and 50% decrease in counts of the green complex after 6 and 12 months, respectively, in subjects treated with SURG.
This might be one reason why smokers are more likely to be resistant to periodontal treatment and are more susceptible to oral disease caused by infection with P. Two local drug delivery systems, one containing MET, the other TET hydrochloride, gave both improvements in microbiological parameters of chronic periodontitis (11). The improvement was greater when the local antibiotic therapies were used as an adjunct to mechanotherapy and the results were sustained 90 days following therapy. This therapy was started immediately after the first session of SRP and was administered in parallel to local TET fibre application. Both AMOX and MET gave significant decreases in counts of many of the bacterial species associated with periodontitis, particularly in the red and orange complexes (12).
For example, SRP was performed in all study subjects at baseline and yet after only 3 months, 20% of the sites had already accumulated dental plaque and 21% of the sites bled on probing. Reduced red complex species were maintained up to 12 months, especially in patients treated with MET. Similar problems were also observed at other study time points implying that the use of either single therapy such as TET or combinational therapies such as AMOX+MET had little impact on the counts. The fibres were removed after 7 days, that is, at the next appointment for quadrant-wise SRP. Subjects who had residual PDs ≥5 mm and BOP received modified Widman flap surgery at weekly intervals as needed. Chlorhexidine, 0.1%, was used as a mouth rinse for 1 min twice daily during the surgical phase and 2 weeks following the last surgical session. However, the study revealed that the use of TET in severely affected sites of subjects who also showed evidence of poor oral hygiene gave no significant improvements in the counts of either the red or the orange complex. At each follow-up visit, the patients’ oral hygiene standard was checked and reinforced when indicated.
Furthermore, at the 12-month recall, all sites with PD ≥5 mm and BOP were subjected to subgingival mechanical debridement.

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