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SANZ et al .
Clinical relevance All studies reported a benefit in terms of PPD reduction when 1% metformin gel was used as an adjunct to subgingival instrumenta - tion. However, studies using single and multiple sites per patients were combined. Balance of benefits and harms All studies included in the review reported that patients tolerated local metformin gel well, without any complications, adverse reac - tions/side-effects, or symptoms of hypersensitivity. Ethical and legal considerations The metformin formulation included in the systematic review is “off- label” and an approved formulation with appropriate quality control (GMP) and patient safety validation is not available. Economic considerations There is an additional cost associated with the use of metformin that is borne by the patient. Applicability The same research group published all data on local metformin; there - fore, the generalizability of the results needs to be confirmed in future larger (multicentre) RCTs, with multi-level analyses accounting for po - tential confounding factors (e.g. medical history, smoking history).
omega-3 fatty acids and low-dose aspirin also warrants fur - ther assessment of its use as an adjunct in the management of periodontitis.
R2.12 | Does the adjunctive use of local metformin improve the clinical outcome of subgingival instrumentation? Evidence-based recommendation (2.12) We recommend not to use local administration of metformin gel as adjunct to subgingival instrumentation. Supporting literature Donos et al. (2019) Quality of evidence Six placebo-controlled RCTs ( n = 313) on locally delivered 1% metformin gel Grade of recommendation Grade A—↓↓ Strength of consensus Strong consensus (0% of the group abstained due to potential CoI)
Background
Intervention Metformin is a second-generation biguanide used to manage type 2 diabetes mellitus. There is evidence suggesting that metformin decreases inflammation and oxidative stress and may also have an osteogenic effect by increasing the proliferation of osteoblasts and reducing osteoclast activity (Araujo et al., 2017). It is therefore plau - sible that this medication may be beneficial in treating a chronic in - flammatory disease like periodontitis. Available evidence Six placebo-controlled RCTs ( n = 313) from the same research group investigated locally delivered 1% metformin gel as an adjunct to sub - gingival instrumentation. All studies reported on PPD reduction at 6 months post-subgingival instrumentation, and a meta-analysis was undertaken combining the six RCTs. Risk of bias Four out of six studies presented some concerns of risk of bias in most of the domains. All studies were published by the same re - search group. While pharmaceutical companies provided metformin, the level of involvement of industry in the analysis and interpreta - tion of the results is unclear. Consistency Meta-analysis of six studies (four considering single sites per patient and two considering multiple sites per patient) indicated that 1% metformin gel as adjunct to subgingival instrumenta - tion led to an improved PPD reduction of 2.07 mm (95% CI [1.83; 2.31]) at 6 months. Heterogeneity between the studies was low ( I 2 = 43%).
6.4 | Intervention: Use of adjunctive chemical agents to subgingival instrumentation
R2.13 | Does the adjunctive use of adjunctive chemotherapeutics (antiseptics) improve the clinical outcome of subgingival instrumentation?
Expert consensus-based recommendation (2.13) Adjunctive antiseptics may be considered , specifically chlorhexidine mouth rinses for a limited period of time, in periodontitis therapy, as adjuncts to mechanical debridement, in specific cases. Supporting literature da Costa, Amaral, Barbirato, Leao, and Fogacci (2017) Grade of recommendation Grade 0—↔ Strength of consensus Consensus (6.3% of the group abstained due to potential CoI)
Background
Intervention In order to control gingival inflammation during periodontal therapy, the adjunctive use of some agents has been proposed. Chlorhexidine mouth rinses have been frequently tested in this indication and fre - quently used in different clinical settings.
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