Fitoterápicos como adjuvante à raspagem e alisamento radicular (RAR) para tratamento não cirúrgico de periodontite em adulto: revisão sistemática de ensaios clínicos randomizados
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Data
2019-12-16
Autores
Escudero, Janaína Vieira Gomes [Unesp]
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Universidade Estadual Paulista (Unesp)
Resumo
A doença periodontal é a infecção crônica mais prevalente em adultos. A gengivite é a forma mais comum desta doença afetando cerca de 50 a 90% dos adultos no mundo, enquanto que a periodontite pode ser a evolução do cenário e danos que causam a gengivite e afeta 56,7% da população em geral. Os fitoterápicos podem ser uma alternativa promissora na busca de tratamento adjuvante à raspagem e alisamento radicular (RAR) para a periodontite. O objetivo deste trabalho foi avaliar os efeitos dos fitoterápicos (e.g., romã, camomila, capim-limão) como adjuvantes à raspagem e alisamento radicular (RAR) quando comparados à pelo menos um dos seguintes tratamentos: padrão, ou seja, RAR isolado (tratamento padrão); RAR em combinação com tratamento antisséptico clorexidina; RAR em combinação com antibióticos sistêmicos; modulação da resposta do hospedeiro com ou sem medicamentos ativo; enxaguatório antimicrobiano; placebo isolado; placebo associado à RAR; nenhuma intervenção; ou outro tipo de terapia complementar e alternativa (e.g., acupuntura, homeopatia) para o tratamento não cirúrgico de pacientes com periodontite. Foi realizada uma revisão sistemática de ensaios clínicos randomizados (ECRs) e/ou quase-randomizados. Os estudos foram obtidos das seguintes bases de dados eletrônicas: MEDLINE, EMBASE, CENTRAL, LILACS e ISI Web of Science. A data da última busca foi em 26 de março de 2019. Revisores independentemente selecionaram e extraíram os dados dos estudos incluídos, e avaliaram o risco de viés dos mesmos. Usamos a abordagem GRADE para avaliar a certeza geral das evidências por desfecho avaliado. Um total de 32 estudos envolvendo 1.225 pacientes foram incluídos na revisão. Resultados provenientes de cinco ECRs com um total de 166 pacientes demonstraram uma diferença estatisticamente significante à favor dos fitoterápicos como adjuvantes à RAR quando comparado ao tratamento padrão (i.e., RAR isolado) na redução da profundidade de sondagem (Diferença de média (DM) -0,51, 95% Intervalo de confiança (IC) -0,78 a -0,23, p = 0,0003; I2=38%, p = 0,17); entretanto não houve diferença estatisticamente significante entre o grupo de fitoterápico adjuvantes à RAR e o tratamento clorexidina associada à RAR no que concerne ao mesmo desfecho (DM -0,03, 95% IC -0,16 a 0,10, p = 0,65; I2=0%, p = 0,61; dois estudos, n = 50 pacientes). Além disso, resultados provenientes de apenas um estudo com um total de 37 pacientes demonstraram uma diferença à favor do tratamento padrão (i.e., RAR isolado) quando comparado ao extrato de gel de semente de linhaça como adjuvante à RAR no aumento de nível de inserção clínica (DM -0,99, 95% IC -1,68 a -0,30, p = 0,005, I2=não aplicável); entretanto não houve diferença entre o grupo de fitoterápico adjuvante à RAR e o tratamento clorexidina em associação à RAR em relação ao mesmo desfecho (DM -0,12, 95% IC -0,78 a 0,54, p = 0,73; I2=19%, p = 0,27; dois estudos, n = 72 pacientes). Não houve diferença estatisticamente significante referente ao desfecho porcentagem de sangramento à sondagem em nenhum dos subgrupos seguintes avaliados: placebo em associação à RAR (DM -1,67, 95% IC -4,82 a 1,48, p = 0,30; I2=0%, p = 0,79, três estudos, n = 88 pacientes) e clorexidina isolada (DM -0,33, 95% IC -7,02 a 6,36, p = 0,92; I2=não aplicável, um estudo, n = 34 pacientes). Ainda referente à porcentagem de sangramento à sondagem, mas como variável dicotômica, foi observada uma diferença à favor do gel de mangostão como adjuvante à RAR quando comparado ao tratamento padrão (i.e., RAR isolado) (Risco relativo (RR) 0,72, 95% IC 0,52 a 0,99, p = 0,05; I2= não aplicável, um estudo, n = 69). No que concerne ao desfecho índice gengival, a clorexidina em combinação à RAR apresentou-se mais efetiva quando comparada ao extrato de camomila (DM 0,07, 95% IC 0,02 a 0,13, p = 0,009; I2=0%, p = 0,51, três estudos, n = 91 pacientes). No que concerne ao extrato de romã, não foi encontrada diferença quando comparada ao tratamento clorexidina em associação à RAR (DM 0,03, 95% IC -0,22 a 0,28, p = 0,83; I2=46%, p = 0,16, três estudos, n = 91 pacientes). Foi encontrada uma diferença estatisticamente significante à favor dos fitoterápicos como adjuvantes à RAR quando comparado ao placebo em associação à RAR ainda em se tratando da redução do índice gengival (DM -0,35, 95% IC -0,47 a -0,22, p < 0,00001; I2=19%, p = 0,29, quatro estudos, n = 259 pacientes). Em relação à redução do índice de placa, houve uma diferença à favor dos fitoterápicos como adjuvantes à RAR quando comparado ao tratamento clorexidina em combinação à RAR (DM -0,13, 95% IC -0,17 a -0,09, p < 0,00001; I2=não aplicável, um estudo, n = 30 pacientes), entretanto quando comparado ao placebo em associação à RAR este apresentou maior índice de redução de placa versus os fitoterápicos como adjuvantes à RAR (DM 0,73, 95% IC 0,04 a 1,43, p = 0,04; I2=97%, p < 0,00001, três estudos, n = 217 pacientes). Entre os estudos elegíveis, não houve evidências relatadas sobre perda dentária e perda óssea, bem como, efeitos adversos, qualidade de vida, e mau hálito. Há baixa certeza das evidências, entretanto, que demonstram a efetividade dos fitoterápicos como adjuvantes à RAR quando comparados ao tratamento com clorexidina em combinação à RAR na redução do índice de placa em pacientes com periodontite. Além disso, há baixa certeza das evidências sugerindo que o fitoterápico como adjuvante à RAR não é inferior à clorexidina associada à RAR em relação aos seguintes desfechos clínicos: profundidade de sondagem e índice gengival em pacientes com periodontite. Da mesma forma, há muito baixa certeza das evidências sugerindo que o fitoterápico como adjuvante à RAR não é inferior à clorexidina associada à RAR em relação os desfecho clínico nível de inserção clínica em pacientes com periodontite. Futuros ensaios clínicos devem avaliar o perfil segurança entre os fitoterápicos e a clorexidina ambos como adjuvantes à RAR, bem como, seus efeitos a longo prazo.
Periodontal disease is a more prevalent chronic infection disease in adults. Gingivitis is the most common form of this disease affecting about 50 to 90% of adults worldwide, while periodontitis may be the evolution of the scenario and damage that causes gingivitis and affects 56.7% of the general population. Herbal medicine may be a promising alternative in seeking adjunctive treatment to scaling and root planing (SRP) for periodontitis. The aim of this review was to evaluate the effects of herbal medicine (e.g., pomegranate, chamomile, lemon grass) as adjuvant to scaling and root planing (SRP) with at least one of the following treatment: SRP only (standard of care, SoC); SRP with antiseptic treatment chlorhexidine; SRP in combination with systemic antibiotics; modulation of host response with or without active drugs, antimicrobial rinsing, placebo, no intervention, other complementary therapy and alternative (eg, acupuncture, homeopathy), for non-surgical treatment of patients with periodontitis. A systematic review of randomized controlled trials (RCTs) and / or quasi-randomized trials was performed. The studies were obtained from the following electronic databases: MEDLINE, EMBASE, CENTRAL, LILACS and ISI Web of Science. The date of the last search was March 26, 2019. Reviewers independently selected and extracted data from included studies, and assessed their risk of bias. We use the GRADE approach to evaluate the overall certainty of evidence by outcomes. A total of 32 studies including 1,225 patients were included in this review. Results from five RCTs with a total of 166 patients showed a statistically significant difference in favor of herbal medicine as adjunct to SRP when compared to SoC in reducing probing depth (Mean Difference (MD) -0.51, 95% Confidence Interval (CI) -0.78 to -0.23, p = 0.0003; I2 = 38%, p = 0.17); however, there was no difference between the herbal medicine as adjuvant to SRP and the SRP-associated chlorhexidine regarding the same outcome (MD -0.03, 95% CI -0.16 to 0.10, p = 0.65; I2 = 0%, p = 0.61; two studies, n = 50 patients). Furthermore, results from only one study with a total of 37 patients showed a difference in favor of SoC when compared to flaxseed gel extract as an adjunct to SRP in increasing clinical insertion level (MD 0.99, 95% CI -1.68 to -0.30, p = 0.005; I2 = not applicable); however there was no difference between the herbal medicine as adjuvant to SRP and the SRP-associated chlorhexidine regarding the same outcome (MD -0.12, 95% CI -0.78 to 0.54 , p = 0.73; I2 = 19%, p = 0.27; two studies, n = 72 patients). There was no difference regarding percentage of bleeding on probing in any of the following evaluated subgroups: placebo in association with SRP (MD -1.67, 95% CI -4.82 to 1.48, p = 0.30; I2 = 0%, p = 0.79, three studies, n = 88 patients) and chlorhexidine alone (MD -0.33, 95% CI -7.02 to 6.36, p = 0.92; I2 = not applicable, one study, n = 34 patients). However, still referring to the percentage of bleeding on probing, but as a dichotomous variable, a difference was observed in favor of mangosteen gel as an adjunct to SRP when compared to SoC (Relative Risk (RR) 0.72 95% CI 0.52 to 0.99, p = 0.05; I2 = not applicable, one study, n = 69). Regarding gingival index, the SRP-associated chlorhexidine was more effective when compared to chamomile extract (MD 0.07, 95% CI 0.02 to 0,13, p = 0.00; I2 = 0%, p = 0.51, three studies, n = 91 patients). However, with regards pomegranate extract there was no difference when compared to the SRP-associated chlorhexidine (MD 0.03, 95% CI -0.22 to 0.28, p = 0.83; I2 = 46%, p = 0.16, three studies, n = 91 patients). Moreover, a statistically significant difference was found in favor of herbal medicine as adjunct to SRP when compared to placebo in association with SRP also in relation to the reduction of gingival index (MD -0.35, 95% CI -0.47 to -0.22), p <0.00001; I2 = 19%, p = 0.29, four studies, n = 259 patients). Regarding the reduction in plaque index, there was a difference in favor of herbal medicine as adjunct to SRP when compared to the SRP-associated chlorhexidine (MD -0.13, 95% CI -0.17 to -0.09, p <0 , 00001; I2 = not applicable, one study, n = 30 patients) and also when compared to placebo in combination with SRP (MD 0.73, 95% CI 0.04 to 1.43, p = 0.04; I2 = 97%, p <0.00001, three studies, n = 217 patients). Among the eligible studies, there was no reported of both tooth and bone loss as well as adverse effects, quality of life, and bad breath. There is low certainty evidence, however, that demonstrates the effectiveness of herbal medicine as adjunct to SRP compared to the SRP-associated chlorhexidine in reducing plaque index in patients with chronic periodontitis. Furthermore, there is low certainty evidence suggesting that herbal medicine as an adjunct to SRP is not inferior to chlorhexidine associated with SRP with regards to the following clinical outcomes: probing depth and reducing gingival index in patients with periodontitis. Similarly, there is very little certainty of evidence suggesting that herbal medicine as an adjunct to SRP is not inferior to chlorhexidine associated with SRP in relation to clinical outcome clinical insertion level in patients with periodontitis. Future clinical trials should evaluate the safety profile between herbal medicine and chlorhexidine both as adjunct to SRP as well as its long-term effects.
Periodontal disease is a more prevalent chronic infection disease in adults. Gingivitis is the most common form of this disease affecting about 50 to 90% of adults worldwide, while periodontitis may be the evolution of the scenario and damage that causes gingivitis and affects 56.7% of the general population. Herbal medicine may be a promising alternative in seeking adjunctive treatment to scaling and root planing (SRP) for periodontitis. The aim of this review was to evaluate the effects of herbal medicine (e.g., pomegranate, chamomile, lemon grass) as adjuvant to scaling and root planing (SRP) with at least one of the following treatment: SRP only (standard of care, SoC); SRP with antiseptic treatment chlorhexidine; SRP in combination with systemic antibiotics; modulation of host response with or without active drugs, antimicrobial rinsing, placebo, no intervention, other complementary therapy and alternative (eg, acupuncture, homeopathy), for non-surgical treatment of patients with periodontitis. A systematic review of randomized controlled trials (RCTs) and / or quasi-randomized trials was performed. The studies were obtained from the following electronic databases: MEDLINE, EMBASE, CENTRAL, LILACS and ISI Web of Science. The date of the last search was March 26, 2019. Reviewers independently selected and extracted data from included studies, and assessed their risk of bias. We use the GRADE approach to evaluate the overall certainty of evidence by outcomes. A total of 32 studies including 1,225 patients were included in this review. Results from five RCTs with a total of 166 patients showed a statistically significant difference in favor of herbal medicine as adjunct to SRP when compared to SoC in reducing probing depth (Mean Difference (MD) -0.51, 95% Confidence Interval (CI) -0.78 to -0.23, p = 0.0003; I2 = 38%, p = 0.17); however, there was no difference between the herbal medicine as adjuvant to SRP and the SRP-associated chlorhexidine regarding the same outcome (MD -0.03, 95% CI -0.16 to 0.10, p = 0.65; I2 = 0%, p = 0.61; two studies, n = 50 patients). Furthermore, results from only one study with a total of 37 patients showed a difference in favor of SoC when compared to flaxseed gel extract as an adjunct to SRP in increasing clinical insertion level (MD 0.99, 95% CI -1.68 to -0.30, p = 0.005; I2 = not applicable); however there was no difference between the herbal medicine as adjuvant to SRP and the SRP-associated chlorhexidine regarding the same outcome (MD -0.12, 95% CI -0.78 to 0.54 , p = 0.73; I2 = 19%, p = 0.27; two studies, n = 72 patients). There was no difference regarding percentage of bleeding on probing in any of the following evaluated subgroups: placebo in association with SRP (MD -1.67, 95% CI -4.82 to 1.48, p = 0.30; I2 = 0%, p = 0.79, three studies, n = 88 patients) and chlorhexidine alone (MD -0.33, 95% CI -7.02 to 6.36, p = 0.92; I2 = not applicable, one study, n = 34 patients). However, still referring to the percentage of bleeding on probing, but as a dichotomous variable, a difference was observed in favor of mangosteen gel as an adjunct to SRP when compared to SoC (Relative Risk (RR) 0.72 95% CI 0.52 to 0.99, p = 0.05; I2 = not applicable, one study, n = 69). Regarding gingival index, the SRP-associated chlorhexidine was more effective when compared to chamomile extract (MD 0.07, 95% CI 0.02 to 0,13, p = 0.00; I2 = 0%, p = 0.51, three studies, n = 91 patients). However, with regards pomegranate extract there was no difference when compared to the SRP-associated chlorhexidine (MD 0.03, 95% CI -0.22 to 0.28, p = 0.83; I2 = 46%, p = 0.16, three studies, n = 91 patients). Moreover, a statistically significant difference was found in favor of herbal medicine as adjunct to SRP when compared to placebo in association with SRP also in relation to the reduction of gingival index (MD -0.35, 95% CI -0.47 to -0.22), p <0.00001; I2 = 19%, p = 0.29, four studies, n = 259 patients). Regarding the reduction in plaque index, there was a difference in favor of herbal medicine as adjunct to SRP when compared to the SRP-associated chlorhexidine (MD -0.13, 95% CI -0.17 to -0.09, p <0 , 00001; I2 = not applicable, one study, n = 30 patients) and also when compared to placebo in combination with SRP (MD 0.73, 95% CI 0.04 to 1.43, p = 0.04; I2 = 97%, p <0.00001, three studies, n = 217 patients). Among the eligible studies, there was no reported of both tooth and bone loss as well as adverse effects, quality of life, and bad breath. There is low certainty evidence, however, that demonstrates the effectiveness of herbal medicine as adjunct to SRP compared to the SRP-associated chlorhexidine in reducing plaque index in patients with chronic periodontitis. Furthermore, there is low certainty evidence suggesting that herbal medicine as an adjunct to SRP is not inferior to chlorhexidine associated with SRP with regards to the following clinical outcomes: probing depth and reducing gingival index in patients with periodontitis. Similarly, there is very little certainty of evidence suggesting that herbal medicine as an adjunct to SRP is not inferior to chlorhexidine associated with SRP in relation to clinical outcome clinical insertion level in patients with periodontitis. Future clinical trials should evaluate the safety profile between herbal medicine and chlorhexidine both as adjunct to SRP as well as its long-term effects.
Descrição
Palavras-chave
Periodontite, Ensaio clínico controlado aleatório, Revisão sistemática, Fitoterapia, Herbal medicine, Phytotherapeutic drugs, Periodontitis, Randomized controlled trial, Systematic review, GRADE approach