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SANZ et al .
Background
Risk of bias The great majority of these studies were industry-funded, and there was a high risk of bias both within and across studies. Consistency Highly consistent across studies, 72 comparisons were included in the primary analysis.
Intervention In order to control gingival inflammation during supportive peri - odontal care, the adjunctive use of some agents has been proposed. These agents are mainly antiseptics but some other agents, such as probiotics, prebiotics, anti-inflammatory agents and antioxidant micronutrients, can be found in the literature. These products are mainly delivered as dentifrices or mouth rinses. Available evidence See also previous section. The adjunctive use of antiseptic agents has been proposed in those subjects who are not able to effectively remove supragingival biofilms by the sole use of mechanical proce - dures. Actually, the recommendations of the XI European Workshop in Periodontology (2014) highlighted that (Chapple et al., 2015) “For the treatment of gingivitis and where improvements in plaque con - trol are required, adjunctive use of anti-plaque chemical agents may be considered. In this scenario, mouth rinses may offer greater ef - ficacy but require an additional action to the mechanical oral hygiene regime”. Recommending adjunctive antiseptics, to mechanical su - pragingival biofilm control, in a specific patient group, instead in the general population, is plausible, but there is no supporting evidence to defend it. Most studies assessing the adjunctive benefits of antiseptic formulations have been performed in general populations, with sta - tistically significant benefits in plaque and gingival indices (Serrano, Escribano, Roldan, Martin, & Herrera, 2015). Therefore, different fac - tors may be considered when deciding whether to recommend the use of an adjunctive agent to control gingival inflammation in patients in supportive periodontal care. It is noted that all patients need to use a toothbrush with a fluoride toothpaste. However, in those subjects who are not able to effectively control supragingival biofilms and/ or gingival inflammation by the sole use of mechanical procedures, a decision is then made whether or not to utilise a toothpaste and/or a mouth rinse that contains a specific active agent (in addition to fluo - ride). This decision would follow a personalized approach to patient care and would need to consider two aspects: • Local factors consider levels of gingival inflammation related to plaque level, accessibility for cleaning, anatomical factors, etc. • General factors consider systemic factors, general health status, frailty, limited dexterity, etc., some of which may be more relevant in elderly patients. The most frequent delivery format for antiseptic agents is den - tifrices and mouth rinses, or even they can be delivered in both, si - multaneously. The obvious benefit of dentifrice delivery is that no other delivery format is needed, and a dentifrice is going to be used anyway. Mouth rinse delivery offers a better distribution around the mouth (Serrano et al., 2015) and better pharmacokinetic properties (Cummins & Creeth, 1992). Some evidence suggests that the ad - junctive use of mouth rinses may provide better outcomes than that of dentifrices. However, the evidence is conflictive and significant
Clinical relevance and effect size Considered as clinically relevant.
Balance of benefit and harm At least 31 studies assessed adverse events and PROMs and staining was the only relevant finding. Economic considerations The issue has not been addressed. For dentifrices, it may not be relevant, since a dentifrice has to be used combined with mechani - cal tooth brushing; for mouth rinse, the extra cost should be taken into consideration. It should also be noted that the evidence base contains studies using products that may no longer be available. Patient preferences Both dentifrices and mouth rinses are widely accepted by the population. Applicability Demonstrated with studies testing large groups from the general population. The adjunctive use of some agents has been proposed in those subjects who are not able to effectively remove supragingival biofilms by the sole use of mechanical procedures, but there is no direct evidence to support this statement. R4.11 | Should adjunctive chemotherapeutics be recommended for patients in supportive periodontal care? Evidence-based recommendation/statement (4.11) A. The use of adjunctive antiseptics may be considered in periodontitis patients in supportive periodontal care in helping to control gingival inflammation, in specific cases. B. We do not know whether other adjunctive agents (such as probiotics, prebiotics, anti-inflammatory agents, antioxidant micronutrients) are effective in controlling gingival inflammation in patients in supportive periodontal care. Supporting literature Figuero, Roldan et al. (2019) Quality of evidence 73 RCTs with, at least, 6-month follow-up A. Grade of recommendation Grade 0—↔ There is a need to define the term of use (e.g. 6 months?) Adverse effects should be taken into account. B. Grade of recommendation Grade 0—Statement: unclear, additional research needed Strength of consensus Consensus (6.9% of the group abstained due to potential CoI)
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