Rajiv Gandhi University of Health Sciences Karnataka



RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

BANGALORE, KARNATAKA.

ANNEXURE II

PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

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|1. |NAME OF THE CANDIDATE AND ADDRESS |Dr. ROOH AFZA, |

| |(IN BLOCK LETTERS) |PG STUDENT, |

| | |DEPARTMENT OF PERIODONTICS, |

| | |THE OXFORD DENTAL COLLEGE HOSPITAL |

| | |AND RESEARCH CENTRE, |

| | |HOSUR ROAD, BOMMANNAHALLI, |

| | |BANGALORE- 560068. |

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|2. |NAME OF THE INSTITUTION |THE OXFORD DENTAL COLLEGE |

| | |HOSPITAL AND RESEARCH CENTRE, |

| | |BANGALORE- 560068. |

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|3. |COURSE OF THE STUDY AND SUBJECT |MASTER OF DENTAL SURGERY, |

| | |PERIODONTICS. |

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|4. |DATE OF ADMISSION TO COURSE |27th MAY, 2011 |

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|5. |TITLE OF THE TOPIC: |

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| |A CLINICAL AND MICROBIOLOGICAL STUDY TO COMPARE THE |

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| |TREATMENT OF PERIODONTAL ABSCESS WITH DRAINAGE AND SCALING |

| |AND ROOT PLANING WITH AND WITHOUT ANTIBIOTICS. |

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|6. |BRIEF RESUME OF INTENDED WORK |

| |6.1 NEED FOR THE STUDY |

| |Periodontal abscess is defined as a localized purulent infection affecting the tissues surrounding a periodontal pocket that can |

| |lead to the destruction of supporting structures.1 Periodontal abscesses often arise as an acute exacerbation of a pre-existing |

| |pocket. It is one of the few clinical situations in periodontics where patients may seek immediate care. Different aetiologies |

| |have been proposed, some of them related to the exacerbation of a non-treated periodontitis, in patients after periodontal |

| |surgery, during preventive maintenance, after systemic antibiotic therapy and as a result of recurrent disease. Conditions in |

| |which periodontal abscess is not related to inflammatory periodontal disease include tooth perforation or fracture and foreign |

| |body impaction.2 The periodontal pathogens found in significant numbers in periodontal abscess include Fusobacterium nucleatum, |

| |Porphyromonas gingivalis, Prevotella intermedia, Peptostreptococcos micros and Tannerella forsythia. Poorly controlled diabetes |

| |mellitus has also been considered as a predisposing factor for periodontal abscess formation. Formation of periodontal abscess has|

| |been reported as a major cause of tooth loss; however, with proper treatment followed by consistent preventive periodontal |

| |maintenance, teeth with significant bone loss may be retained for many years. |

| |Periodontal diseases are one of the most common bacterial infections affecting the oral cavity and the best way to treat them is |

| |to control the causative organisms. It is clear that systemically administered antibiotics provide clinical benefit in the |

| |treatment of periodontal abscesses. If antibiotics confer therapeutic advantage, should they be given to all patients with |

| |periodontal abscess? If not who should receive these agents and how severe does the periodontal infections have to be in order to |

| |justify the use of an antimicrobial agent? 3 |

| |Thus the purpose of this study is to assess if antibiotic therapy is required as a routine in all cases of periodontal abscesses. |

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| |6.2 REVIEW OF LITERATURE |

| |In a clinical and microbiological study 20 patients suffering from abscess of periodontal origin were treated and followed |

| |clinically and microbiologically for 6 months. Microbiological examination was performed using culture technique. Treatment |

| |included supragingival scaling, drainage and irrigation of the periodontal pocket with 0.85% Sodium Chloride and systemic |

| |Tetracycline administration. After 6 months, abscess sites demonstrated a reduced probing depth, less bleeding on probing and gain|

| |of attachment. Abscess sites showed no Porphyromonas gingivalis and the proportion of Prevotella intermedia was significantly |

| |reduced 6 months after treatment.4 |

| |A retrospective study focused on the frequency of tooth loss due to periodontal abscess among 42 patients who were treated by a |

| |single clinician over a 5 to 29 year period showed that a total of 109 teeth were affected by periodontal abscess of which 49 |

| |teeth were lost and 60 were successfully maintained over an average of 12.5years. This suggests that teeth with a history of |

| |periodontal abscess can be treated and maintained for several years.5 |

| |In a microbiological study involving 23 adult periodontitis patients, the occurrence of β-lactamase producing bacteria was |

| |determined. β-lactamase in whole sub gingival plaque was detected in 12 patient samples. It was concluded that β-lactamase |

| |activity in sub gingival bacteria is a common feature.6 |

| |In a longitudinal clinical study the clinical and microbiological efficacy of 2 different antibiotic regimes were compared in the |

| |treatment of acute periodontal abscesses. Microbiological samples were taken from the lesion and the patient was randomly assigned|

| |to one of the 2 antibiotic regimes: Azithromycin or Amoxicillin. Microbiologically, short term reductions were detected with both |

| |antibiotics, however fast recolonization occurred after a month. No significant differences were found between both treatment |

| |regimes. Antibiotic susceptibilities demonstrated no resistances for Amoxicillin / Clavulanate, while 2- 3 strains of each subject|

| |studied pathogen were resistant to Azithromycin.7 |

| |Two systematic reviews have indicated that systemically administered antibiotics provide a clear clinical benefit in terms of mean|

| |periodontal attachment level gain post therapy when compared with groups not receiving these agents. 8, 9 |

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| |In a descriptive clinical and microbiological study, 54 subjects presented with 60 periodontal abscesses, samples were cultured |

| |for anaerobic and facultative bacteria. Selected isolates of Porphyromonas gingivalis and Prevotella intermedia were used to test |

| |susceptibility to Amoxicillin, Azithromycin, Tetracycline and Metronidazole. Some periodontopathogens showed antimicrobial |

| |resistance to Tetracycline, Metronidazole and Amoxicillin, but not to Azithromycin. Hence, rationale use of antibiotic adjunctive |

| |therapy in abscess treatment should be taken into account.10 |

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| |6.3 AIMS AND OBJECTIVES OF THE STUDY |

| |To assess the prevalence of Fusobacterium nucleatum, Porphyromonas gingivalis and Prevotella intermedia at sites with periodontal |

| |abscess. |

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| |To assess the influence of drainage, scaling and root planing on the prevalence of Fusobacterium nucleatum, Porphyromonas |

| |gingivalis and Prevotella intermedia at sites with periodontal abscess. |

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| |To assess the influence of systemic antibiotics on the prevalence of Fusobacterium nucleatum, Porphyromonas gingivalis and |

| |Prevotella intermedia at sites with periodontal abscess. |

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|7. |MATERIAL AND METHODS |

| |7.1 SOURCE OF DATA |

| |Patients diagnosed with periodontal abscesses will be selected based on the criteria mentioned below from the Department of |

| |Periodontics, The Oxford Dental College, Hospital and Research Centre, Bommanahalli, Bangalore. |

| |The purpose of the study will be explained in detail to the subjects and an informed consent will be obtained. |

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| |7.2 METHOD OF COLLECTION OF DATA |

| |INCLUSION CRITERIA :- |

| |Age group between 18 to 60 years. |

| |Patients complaining of localised pain and swelling related to a periodontal area. |

| |Affected area showing oedema, swelling and redness. |

| |On periodontal examination the swelling should be associated with a periodontal pocket with bleeding and suppuration. |

| |Non vital teeth with a clear primary periodontal lesion (presence of a deep periodontal pocket). |

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| |EXCLUSION CRITERIA :- |

| |Patients with periodontal abscess associated with systemic complications like fever and cellulitis are excluded. |

| |Patients with known allergies to Penicillin, Macrolides or Lactose. |

| |Use of antibiotics 4-5 weeks prior to the study. |

| |Other systemic infections which could need additional medication. |

| |Endodontal abscesses are excluded based on vitality tests and radiographic examination. |

| |Pregnant and lactating women. |

| |Medically compromised patients. |

| |Systemic diseases. |

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| |7.3 STUDY DESIGN :- |

| |In this Comparative study a total of 30 subjects satisfying the above mentioned criteria will be recruited and categorized |

| |randomly into 2 groups Group A and Group B of 15 subjects each. |

| |Group A - Periodontal abscess group without systemic antibiotic therapy. |

| |Group B - Periodontal abscess group with systemic antibiotic therapy. |

| |Amoxicillin - 500 mg 3 times a day for 5 days. |

| |Detailed instructions are given to patients regarding timing, dosages and possible adverse effects. In order to assess drug |

| |compliance, patients are asked to bring the empty blisters at the 2nd visit. |

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| |BASELINE VISIT :– |

| |At baseline, the following procedures are carried out. |

| |a) Photographs of the abscess area. |

| |b) Blood sampling. |

| |c) Microbiological sampling. |

| |d) Clinical examination. |

| |The following clinical parameters will be recorded for all the patients:- |

| |Plaque Index (Silness and Loe). |

| |Gingival Index (Loe and Silness). |

| |Bleeding index (Ainamo and Bay). |

| |Probing pocket depth in mm. |

| |Clinical attachment level in mm. |

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| |Group A: Subgingival microbiological samples will be collected from the periodontal pocket associated to the abscess prior to |

| |drainage following which scaling and root planing will be rendered. Further the patient will be recalled after 5 days and samples |

| |will be collected again. |

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| |Group B: Subgingival microbiological samples will be collected prior and after abscess drainage as mentioned in group A but |

| |antimicrobials will be administered after drainage for 5 days. |

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| |2nd VISIT ( 5 Days after baseline) |

| |In the 2nd visit the same clinical and microbiological variables are assessed again. A detailed history of any adverse reaction or|

| |compliance problems related to the assigned medication is recorded. In addition to this, occurrence of other health problems or |

| |intake of other medications is also recorded. |

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| |METHOD OF COLLECTION OF SAMPLE: |

| |After the clinical parameters are recorded, supragingival plaque is removed from the tooth with sterile gauze and isolated with |

| |cotton rolls and subgingival microbiological samples are collected from the periodontal pocket associated to the abscess with |

| |sterile curettes and placed into transport media. |

| |The results obtained will be statistically analyzed and compared for the two groups using appropriate statistical analysis |

| |(Student T test). |

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| |Duration of the study |

| |1 year. |

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| |7.4 Does this study require any investigation or interventions to be conducted on patients or other human beings? |

| |Yes, subgingival microbiological samples will be collected from the patients and subjected to PCR analysis, blood samples will be|

| |analyzed for the evaluation of routine variables, abscess will be drained, scaling and root planing rendered and systemic |

| |antibiotics advised. |

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| |7.5 Has ethical clearance been obtained from your institution? |

| |Yes, a copy of certificate is enclosed. |

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| |LIST OF REFERENCES: |

| |Meng HX: Periodontal abscess. Ann Periodontol 1999; 4(1): 79-83. |

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| |Kareha MJ, Rosenberg ES, Dehaven H: Therapeutic considerations in the management of a periodontal abscess with an intrabony |

| |defect. J Clin Periodontol 1981; 8: 375- 386. |

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| |Haffajee AD. Systemic antibiotics: To use or not to use in the treatment of periodontal infections. That is the question. J Clin |

| |Periodontol 2006; 33: 359- 361. |

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| |Hafstrom CA, Wikstrom MB, Renvert SN, Dahlen GG: Effect of treatment on some periodontopathogens and their antibody levels in |

| |periodontal abscess. J Periodontol 1994; 65: 1022- 1028. |

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| |Mcleod DE, Lainson PA, Spivey JD: Tooth loss due to periodontal abscess: a retrospective study. J Periodontol; 1997; 68(10): 963- |

| |966. |

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| |Van Winkelhoff AJ, Winkel EG, Barendregt D, Dellemijn- Kippuw N, Stijne A, Van der Velden U: β-lactamase producing bacteria in |

| |adult periodontitis. J Clin Periodontol 1997:24(8): 538-543. |

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| |Herrera D, Roldan S, O’ Connor A, Sanz M: The periodontal abscess (II). Short term clinical and microbiological efficacy of two |

| |systemic antibiotic regimes. J Clin Periodontol 2000; 27: 395-404. |

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| |Herrera D, Sanz M, Jepsen S, Needleman I, Roldan S: A systemic review on the effect of systemic antimicrobials as an adjunct to |

| |scaling and root planning in periodontitis patients. J Clin Periodontol 2002; 29(3): 136-159. |

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| |Haffajee AD, Socransky SS, Gunsolley JC: Systemic anti-infective periodontal therapy. A systematic review. Ann Periodontol 2003; |

| |8(1): 115-181. |

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| |Jaramillo A, Arce RM, Herrera D, Betancourth M, Botero JE, Contreras A: Clinical and microbiological characterization of |

| |periodontal abscesses. J Clin Periodontol 2005; 32: 1213-1218. |

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|9. |SIGNATURE OF THE CANDIDATE | |

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|10. |REMARKS OF THE GUIDE | |

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|11. |NAME AND DESIGNATION OF THE GUIDE |DR. SHOBA. C |

| | |READER |

| | |DEPARTMENT OF PERIODONTICS |

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| |SIGNATURE | |

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|12. |HEAD OF THE DEPARTMENT |DR. A. V. RAMESH |

| | |PROFESSOR AND HEAD |

| | |DEPARTMENT OF PERIODONTICS |

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| |SIGNATURE | |

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|13. |REMARKS OF PRINCIPAL | |

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| |SIGNATURE | |

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