Comparative evaluation of locally delivered probiotics Saccharomyces boulardii-prebiotics Fructooligosaccharide mixture and tetracycline fibers as an adjunct to scaling and root planning in the management of patients with chronic periodontitis: A Randomised Clinical Trial

Chronic periodontitis is characterized by inflammation and destruction of the supporting tissues of the teeth, including the gums and bone, primarily caused by bacterial infections. It is of multifactorial etiology mainly the presence of pathogenic bacteria, the absence of “beneficial bacteria” and the susceptibility of the host. Initial therapy focuses on the reduction of periodontopathogens by scaling and root planing (SRP) and oral hygiene instructions. Although initially the number of pathogens can be greatly reduced by Scaling and root planing, periodontal pathogens quickly re-colonize the treated niches in the oral cavity. Thus adjuvant therapies—antibiotic therapy, antimicrobial photodynamic therapy, and probiotic therapy have been used recently. Probiotics have gained attention in the field of periodontal health as a potential adjunctive therapy for chronic periodontitis as it reduce inflammation, improve gum health, and inhibit the growth of periodontal pathogens. The rationale behind using probiotics in chronic periodontitis is conversion of the dysbiotic microbiome to a beneficial symbiotic microbiome thus they are able to promote a healthier balance of oral microbiota by introducing beneficial bacteria, which may help counteract the harmful effects of pathogenic bacteria associated with periodontal disease. Studies have demonstrated that probiotics can reduce periodontopathogens, improve periodontal clinical parameters, decrease the levels of proinflammatory cytokines, and potentiate the effects of SRP. However, the effectiveness of probiotics can vary depending on factors such as the strain, dosage, and formulation used, as well as individual patient characteristics. Saccharomyces boulardii is a non-pathogenic yeast used as a preventive and therapeutic agent for the treatment of a variety of gastrointestinal diseases as a live non-pathogenic microbial food or food supplement that beneficially affects the host by improving its intestinal microbial system. The probiotics use the prebiotics as a food source, which enables them to survive for a longer period of time inside the human body than would otherwise be possible. Local delivery of antimicrobial agents includes oral rinses, subgingival irrigation and controlled release delivery system. They have been evaluated in several forms such as gels, strips, fibers, chips, ointments and using different antimicrobial agents such as tetracycline, doxycycline, metronidazole, minocycline and chlorhexidine. Goodson introduced the use of tetracycline as a local drug delivery agent for the treatment of periodontal diseases. One such local drug delivery system is available in the form of resorbable tetracycline fibers (Periodontal Plus AB®). The tetracycline groups of drug are among the most widely used agents to treat periodontal disease both systemically and also as local drug delivery agent which have the advantage of avoiding the deleterious effect of systemic administration including the development of resistance, suppression of normal flora and poor patient compliance. Tetracycline is a promising drug for controlling progression of periodontal diseases by their ability to reduce microbial burden, to block collagenase activity, and to potentially inhibit bone loss. Meta-analysis published in 2003 reported a significant mean reduction in probing depth (PD) in favor of local tetracycline therapy and suggested more advantage with fibers compared to other devices. Another Meta-analysis published in 2016 showed significant improvement in periodontal parameters such as clinical attachment level (CAL), PD, and sulcular bleeding index in favor of tetracycline as local drug delivery compared to placebo. Saccharomyces is the best studied eukaryote and a valuable tool for most aspects of basic research on eukaryotic organisms due to its unicellular nature and easy amenablity to genetic manipulation. Multiple animal studies have been conducted which have proved that Saccharomyces when used as a local probiotic does not result in any adverse effects on periodontal tissues and when used as single drug or as an adjuvant, the probiotic was effective at controlling periodontitis. However there is very limited knowledge to evaluate its efficacy as a probiotic in humans and its effects on Keystone periodontal pathogen, Porphyromonas gingivalis. So this study is being conducted to evaluate and compare the effect of locally delivered probiotic-prebiotic mixture comprising Saccharomyces boulardi and Fructooligosaccharide with tetracycline fibers as an adjunct to SRP in treating Chronic Periodontitis.