10.59987/ads/2012.2.76-81
Aims. The aim of this clinical trial was to compare clinical and biochemical healing outcomes following ultrasonic mechanical instrumentation versus ultrasonic mechanical instrumentation associated with topical subgingival application of amino acids and sodium hyaluronate gel.
Methods. Eleven systemically healthy subjects with moderate-severe chronic periodontitis, who had four sites with pocket probing depth and clinical attachment level greater than or equal to 5 mm were randomly assigned to two different types of treatment: two pockets were treated with ultrasonic debridement (Control Group) and two pockets with ultrasonic mechanical instrumentation associated with 0,5 ml of amino acids and sodium hyaluronate gel (Test Group). Probing depth, clinical attachment level, plaque index and bleeding on probing were recorded at baseline, 45 and 90 days. Levels of calprotectin and myeloperoxidase activity in gingival crevicular fluid were assessed at baseline and on day 7 and 45.
Results. Statistical significance was found between baseline and day 45 in relation to probing depth reduction and bleeding on probing between groups for both of the tested treatments. Significant reductions in μg/sample of calprotectin and myeloperoxidase were found after 1-week and an increase at 45 days in both groups. There were no statistically significant differences between other variables evaluated in this study. Conclusions. These data suggest that subgingival application of hyaluronic acid following ultrasonic mechanical instrumentation is beneficial for improving periodontal parameters
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Annali di stomatologia
myeloperoxidase
Effectiveness of adjunctive subgingival administration of amino acids and sodium hyaluronate gel on clinical and immunological parameters in the treatment of chronic periodontitis
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Original Article
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R. Di Lenarda
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Effectiveness of adjunctive subgingival administration of amino acids and sodium hyaluronate gel on clinical and immunological parameters in the treatment of chronic periodontitis
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                                                                                            Original article


Effectiveness of adjunctive subgingival administration of
amino acids and sodium hyaluronate gel on clinical and
immunological parameters in the treatment of chronic




                                                                                    li
periodontitis




                                                                                 na
Lorenzo Bevilacqua, DDS, MS1                           crevicular fluid were assessed at baseline and on
Jessica Eriani, MD2                                    day 7 and 45.
Ilde Serroni, DDS, MS3                                 Results. Statistical significance was found between




                                                                              io
Giuliana Liani, MD2                                    baseline and day 45 in relation to probing depth re-
Violetta Borelli, MD4                                  duction and bleeding on probing between groups for
Gaetano Castronovo, MD1                                both of the tested treatments. Significant reductions




                                                                           az
Roberto Di Lenarda, DDS, MS1                           in µg/sample of calprotectin and myeloperoxidase
                                                       were found after 1-week and an increase at 45 days
                                                       in both groups. There were no statistically signifi-
1
  Department of Clinical Medical Sciences,             cant differences between other variables evaluated




                                                               n
Surgical and Health                                    in this study.
University of Trieste, Trieste, Italy                  Conclusions. These data suggest that subgingival




                                                            er
2
  Dental hygienist, Private practice, Trieste, Italy   application of hyaluronic acid following ultrasonic
3
  Private practice, Gorizia, Italy                     mechanical instrumentation is beneficial for improv-
4
  Department of Life Sciences                          ing periodontal parameters.
University of Trieste, Trieste, Italy


Corresponding author:
                                                  nt   Key words: hyaluronic acid, periodontitis, calprotec-
                                                       tin, myeloperoxidase.
                                                iI
Lorenzo Bevilacqua, MD
Aggregate Professor                                    Introduction
University Department of Clinical Medical Sciences
                                              on

Surgical and Health of Trieste, Trieste, Italy         A successful treatment of periodontal disease is based
UCO of Dental Sciences of Trieste                      on an adequate maintaining of infection control in the
Piazza dell’Ospitale 1                                 subgingival area. According to recent systematic re-
34100 Trieste, Italy                                   views (1,2), there is no major difference in the efficacy
                                      i


Phone: 0403992567 – Fax: 0403992665                    of debridement techniques of plaque and calculus from
                                   iz


E-mail: l.bevilacqua@fmc.units.it                      root and tooth surfaces using manual or ultrasonic in-
                                                       strumentation. Ultrasonic mechanical instrumentation
                                                       combined with effective self-performed supragingival
                   Ed




                                                       plaque control measure, allows infection control by al-
Summary                                                tering the subgingival ecological environment through
                                                       disruption of the microbial biofilm and suppression of the
Aims. The aim of this clinical trial was to compare    inflammation (3).
clinical and biochemical healing outcomes following    This goal is frequently not completely attainable; it is
ultrasonic mechanical instrumentation versus ultra-    nearly impossible to expect to set the root completely
 IC




sonic mechanical instrumentation associated with       free from calculus specially in deeper pockets. Probing
topical subgingival application of amino acids and     of the root surface for detection of remaining deposits
sodium hyaluronate gel.                                is an unreliable method to determine whether adequate
C




Methods. Eleven systemically healthy subjects          debridement has been achieved, while clinical signs of
with moderate-severe chronic periodontitis, who        resolution of the inflammatory lesion would indicate suf-
had four sites with pocket probing depth and clini-    ficient removal of biofilm/calculus (4).
cal attachment level greater than or equal to 5 mm     Several recent studies have demonstrated additional
©




were randomly assigned to two different types of       improvements in clinical parameters using local or sys-
treatment: two pockets were treated with ultrasonic    temic antimicrobial agents (5-7).
debridement (Control Group) and two pockets with       Nevertheless, antibacterial agents locally or systemically
ultrasonic mechanical instrumentation associated       applied in periodontal pockets, proved to be more effec-
with 0,5 ml of amino acids and sodium hyaluronate      tive only when they were used in combination with ultra-
gel (Test Group). Probing depth, clinical attachment   sonic mechanical instrumentation. Physical disruption of
level, plaque index and bleeding on probing were       the biofilm is fundamental for the control of periodontal
recorded at baseline, 45 and 90 days. Levels of cal-   diseases (8). The use of systemic antibiotics should be
protectin and myeloperoxidase activity in gingival     limited because of the development of resistant organ-

Annali di Stomatologia 2012; III (2): 75-81                                                                   75
L. Bevilacqua et al.



isms, allergic reactions and drug interactions.                 Materials and methods
Some articles proposed topical applications of hyaluron-
ic acid (HA) to complement mechanical debridement               Patient selection and pocket selection
(9,10). HA is a non-sulfated glycosaminoglycan with a           The study design was a split-mouth clinical trial of
high molecular weight. It is one of the components of the       12-weeks duration.




                                                                                              li
extracellular matrices of the connective tissue and was         11 healthy patients with moderately advanced chronic
detected in the gingiva (11,12). It has an anti-inflamma-       periodontitis, 7 males and 4 females (mean age was 51




                                                                                           na
tory and anti-edematous effect (13) and promotes wound          years SD ± 9,8), were recruited for the study following
healing (14). Hyaluronan gel application demonstrated a         a screening examination including full-mouth probing
better reduction of the clinical parameters and inflamma-       and radiographic evaluation. The following criteria were
tory infiltrate in the treatment of plaque-induced gingivitis   used:




                                                                                        io
(15,16). Recently, Pistorius and colleagues confirmed a
reduction in the sulcus bleeding index and in the gingival      Inclusion criteria:
crevicular fluid (GCF), but not in the plaque values after      • age 40 to 70 years,




                                                                                     az
topical hyaluronic acid application in gingivitis therapy       • a minimum of 18 teeth,
(17).                                                           • at least two sites per quadrant with probing depth
Currently, researchers are establishing the potential ben-      (PPD) and clinical attachment level (CAL)≥ ³5 mm.
efits of local subgingival application of HA adjunctive to




                                                                        n
scaling and root planing for the treatment of periodontitis     Exclusion criteria:
owing to its tissue healing and regenerative properties         • use of locally or systemic antimicrobial agents 6




                                                                     er
(14). Research is also under way to establish that topical      months before the study,
applications of HA in alveolar bony defects accelerate          • subgingival instrumentation within 6 months before the
periodontal wound healing (18).                                 baseline examination,
In 2001 Engstrom’s clinical, immunological and microbi-         • previous periodontal therapy during the last 6 months,

                                             nt
ological responses to hyaluronan were studied to evalu-
ate the anti-inflammatory effect on surgical and non-sur-
gical periodontal treatment (9). Parameters considered
                                                                • pregnancy and lactation period,
                                                                • smokers,
                                                                • systemic diseases that could possibly influence the
                                           iI
were periodontal probing depth, gingival crevicular fluid       condition of the periodontal tissue and the subgingival
immunoglobulin G (IgG), C3, prostaglandin E2 (PGE2)             microflora.
and presence of plaque.
                                         on

The anti-inflammatory effect of hyaluronan could not be         Power calculation based on the detection of a difference
verified in this study in relation to the immune responses      in the mean PPD reduction of 0,5 mm between differ-
(IgG, C3 and PGE2). In another study by Xu and col-             ent treatment, standard deviation (SD) 0,035, a error de-
leagues it was found that no clinical or microbiological        fined to 0.05 and b error defined to 0.20, revealed that
                                 i


improvement was achieved by the adjunctive use of HA            at least 18 sites in each treatment were required (PS
                              iz


gel compared to scaling and root planing alone in the           2.1.31 for windows) (24).
treatment of periodontitis. Only sulcus flow rate was af-       Approval of the study protocol by the Ethics Committee
fected by the use of HA gel in terms of a more rapid            at Azienda Ospedaliero-Universitaria “Ospedali Riuniti”
                  Ed




reduction in the test sites (10).                               of Trieste (n. 27/2008) was obtained, and all participat-
In 2009 Johannsen asserted that the application of hy-          ing subjects provided informed consent before the start
aluronan gel in conjunction with scaling and root planing       of the study.
may have a beneficial effect on periodontal health in pa-
tients with chronic periodontitis (19).                         Assessment baseline
 IC




Recent reports showed that a gel containing HA promot-          The following variables were recorded for each site:
ed wound healing in post-surgical wounds (20-22).               Plaque index (PI) (25): presence/absence of plaque at
In order to determine the amount of HA needed to lead           the cervical area of the tooth.
to clinically significant periodontal healing we planned to     Bleeding on probing (BOP) (26): presence/absence of
C




evaluate the clinical and the putative anti-inflammatory        bleeding within 15s following pocket probing.
effects of application of amino acids and sodium hyal-          Clinical attachment level (CAL): distance between a
uronate gel as an adjunct to ultrasonic mechanical in-          fixed reference point on the tooth (cemento enamel junc-
strumentation in patients with chronic periodontitis. To        tion, CEJ, or the margin of a restoration) to the bottom of
©




this purpose as clinical parameters we evaluated PPD,           the clinical pocket, measured with a manual periodontal
CAL, plaque index (PI) and bleeding on probing (BOP).           probe (UNC15 Hu-Friedy®, Chicago, IL, USA).
As inflammatory parameters we evaluated calprotectin            Probing depth (PPD): distance from gingival margin to
concentration and myeloperoxidase activity in gingival          the bottom of the clinical pocket, measured with a man-
crevicular fluid, since these are directly related with both    ual periodontal probe (UNC15 Hu-Friedy®, Chicago, IL,
the extent of polymorphonuclear neutrophils (PMNs) in-          USA).
filtration and the severity of periodontal disease (8,23).      In another session were recorded in the same site:
                                                                Level calprotectin and myeloperoxidase (MPO): The
                                                                selected area was isolated with cotton rolls and gently

76                                                                                    Annali di Stomatologia 2012; III (2): 75-81
Effectiveness of adjunctive subgingival administration of amino acids and sodium hyaluronate gel on clinical and immunological



air-dried. Then, a perio paper strip (PerioCol Collection            (Maxi Mixer 714, Asal Srl., MI, Italy) and eluted by cen-
Strip, Oraflow, Plainview, NY, USA) was inserted into the            trifugation at 3000 cycles/min for 5min (MSE, Sanyo,
sulcus at PPD less than 1 mm and removed after 10s.                  Singapore).
Strips visibly contaminated with blood were discarded.               The crevicular protein content was quantified with the
After the measurements, samples were stored separate-                Bradford method (28) using bovine - serum - albumin




                                                                                                     li
ly in 200 µl sterile phosphate-buffered saline at -80°C              (BSA) as standard.
until further processing.




                                                                                                  na
Gingival crevicular fluid volume (GCF): after 10 minutes             Calprotectin
of the quantitative evaluated of calprotectin and MPO,               Crevicular calprotectin levels were measured by en-
sites were reisolated with new cotton rolls and gently air-          zyme-linked-immunosorbent assay using a commercial
dried. Then new perio paper strip (PerioCol Collection               kit (Calprest, Eurospital, TS, Italy). The assays were per-




                                                                                               io
Strip, Oraflow, Plainview, NY, USA) was inserted into the            formed according to the manufacturer’s instructions, and
sulcus and removed after 10s. The gingival crevicular                the results referred to a calibration curve expressed in
fluid volume was determined using a calibrated moisture              µg/µl. Samples were diluted using assay buffer to 1:100




                                                                                            az
meter (Periotron, Siemens, Bensheim, Germany) and                    and assayed in triplicate.
calculated in µl from a standard curve. The Periotron
was calibrated by pipetting known volumes of four dif-               Salivary myeloperoxidase (MPO)
ferent liquids (phosphate-buffered saline, human saliva,             Crevicular peroxidase (MPO) activity was calculated




                                                                              n
human serum, PBS phosphate buffered saline) on perio                 from the rate of H202-dependent oxidation of TMB (29).
paper strips (27). Calibration to baseline was performed             Briefly the activity of crevicular MPO was determined




                                                                           er
with a dry perio paper.                                              at room temperature in 96 wells microtiter plate using
                                                                     a reaction mixture containing 1mM (final concentration)
Treatment procedures                                                 tetramethylbenzidine (TMB) (29) [added from a 25 mM
After initial measurements and collection had been done,             stock solution in dimethylsulphoxide (DMSO)] as sub-

                                                  nt
the selected patients have been treated with full-mouth
subgingival debridement using a piezoceramic ultrason-
ic instrument (Piezosteril 5, Castellini, MI, Italy). The in-
                                                                     strate, 0,02% cetyltrimethylammonium bromide (CTAB).
                                                                     The reaction was started by adding 0,30 mM hydrogen
                                                                     peroxide (final concentration), stopped after 2 minutes
                                                iI
strumentation was considered completed when the root                 by adding 0,4N H2SO4 (final concentration) and the re-
surface was clinically judged to be clean and smooth.                action product was quantitated spectrophotometrically at
Then, a split mouth method design was applied. After ul-             413nm. Since PMN are the only source of peroxidase
                                              on

trasonic debridement, four sites, two per quadrant, were             activity in the crevicular fluid (30) the concentration of
randomly allocated (computer generated randomization                 MPO in crevicular fluid was calculated by referring to a
list, Random Generator) to test group or control group.              calibration curve obtained with pure human MPO (Rz
The additional treatment at the test sites consisted of              0.8) prepared from human neutrophils (31) as previously
                                      i


subgingival administration of 0,5 ml of amino acids and              described (32).
                                   iz


sodium hyaluronate gel (Aminogam Ò A, lotto 190308A,                 Calprotectin and peroxidase data were presented in µg/
Errekappa Euroterapici Spa, MI, Italy) by a syringe with             µl for concentrations and in µg/sample for total amounts
blunt needle placed 3 mm to bottom of the clinical pock-             in the selected sites.
                   Ed




et; in the same way 0,5 ml of placebo gel (Aminogam Ò
B, lotto 190308B, Errekappa Euroterapici Spa, MI, Italy)             Statistical analysis
was applied in two control sites. Operator did not know              Statistics were performed with the site as the unit of anal-
the contents of the gel. Aminogam A and Aminogam B                   ysis. The mean of all the analysed periodontal param-
were made at the sites following the same procedure at               eters was calculated. The c2 test was used to determine
 IC




7, 15, 30 and 45 days.                                               the differences in dichotomous variables (PI and BOP).
The patient was instructed not to drink or eat or tooth-             The distribution of continuous variables was initially ana-
brush for 1 hour after device administration. All patients           lysed with Kolmogorov-Smirnov and Shapiro-Wilks. Dif-
were included in a personalized hygiene program.                     ferences between mean values for gingival crevicular
C




                                                                     fluid volume were statistically analysed by the use of the
Clinical and biochemical assessment after treatment                  repeated measurements analysis of variance. Differenc-
At day 45 and day 90, a dental hygienist registered new              es in PPD and CAL between the groups at baseline, day
values of PI, PPD, CAL and BOP for all of the treated                45 and day 90 were tested by the use of Mann-Whitney
©




sites and oral hygiene motivation was given when indi-               U-test with exact test Monte Carlo Sig (1-talied) based
cated.                                                               on 10000 sampled tables. Changes of concentrations of
The quantity of calprotectin, MPO and gingival crevicu-              calprotectin and MPO were analysed by non-parametric
lar fluid volume was evaluated and recorded at test and              test. Statistical significance was defined as p<0.05.
control sites at 7 and 45 days.                                      A software program (SpSS 16.0 for Windows, SPSS
                                                                     Inc., Chicago, IL, USA) was used for all calculations.
Biochemical analyses
To extract the GCF from the perio paper strip, the sam-
ples were thawed, vortexed for 60 s by a vortex-mixer

Annali di Stomatologia 2012; III (2): 75-81                                                                                      77
L. Bevilacqua et al.



Results                                                           Bleeding on probing (BOP)
                                                                  The number of bleeding sites was markedly reduced
All eleven participants completed the study and there             following both treatments. At 45 days, the BOP was re-
were not protocol deviations. No adverse effects were             duced from 72,7% to 27,3% in sites treated with only
reported (Fig. 1).                                                ultrasonic instruments and from 72,7% to 9,1% in sites




                                                                                                li
                                                                  treated with ultrasonic instruments and amino acids and
                                                                  sodium hyaluronate gel. At re-evaluation at 90 days,




                                                                                             na
                                                                  bleeding sites were reduced in both groups but those
                                                                  treated only with non-surgery mechanical periodontal
                                                                  therapy obtained higher BoP scores (test group=4,5%;
                                                                  control group =18,2%).




                                                                                          io
                                                                  There was statistically significant difference in BOP be-
                                                                  tween the two treatment groups (p<0.05).




                                                                                       az
                                                                  Clinical attachment level (CAL)
                                                                  At re-evaluation at 45 days a CAL gain amounted 0.64
                                                                  mm (test group) and 0,55 mm (control group) was ob-
                                                                  tained. At 90 days, CAL mean was reduced from 5,91




                                                                          n
                                                                  mm to 4,86 mm in test group, from 5,91 mm to 5,05 mm
                                                                  in control group.




                                                                       er
                                                                  There was no statistically significant difference in CAL
                                                                  gain between baseline and re-examination intervals (45
                                                                  and 90 days) for both groups (p>0.05). There was no
                                                                  statistically significant difference in CAL gain between


Figure 1 - Flow diagram of the trial.          nt                 sites treated with ultrasonic instruments and those treat-
                                                                  ed with mechanical instruments combined with amino
                                                                  acids and sodium hyaluronate gel (p>0.05).
                                             iI
Clinical findings                                                 Probing pocket depth (PPD)
The clinical characteristics of the sites included in the         A marked reduction of probing pocket depth was ob-
                                           on

study are reported in Table 1.                                    served in both groups. At the 45 days re-examination,
                                                                  mean PPD reduction was 0,96 mm for test group and
Plaque index score (PI)                                           0,54 mm for control group. At 90 days, PPD was reduced
The plaque index score in the two study groups im-                from 6,36 mm to 5,36 mm in sites treated with ultrasonic
                                    i


proved during the study period. The PI was reduced by
                                 iz


31,8% in the test group, by 36,4% in the control group.
No statistically significant difference between the two
treatment groups was observed at any of the examina-
                  Ed




tion intervals.
 IC
C
©




                                                                  Table 2 - Biochemical group characteristics; mean values (95%
                                                                  CI).
                                                                  *N=21 #p<0.001; #p-values represent differences between test
Table 1 - Clinical group characteristics; mean values (95% CI).   group and control group.


78                                                                                       Annali di Stomatologia 2012; III (2): 75-81
Effectiveness of adjunctive subgingival administration of amino acids and sodium hyaluronate gel on clinical and immunological



instruments only and from 6,14 mm to 4,64 mm in sites                sodium hyaluronate gel in adjunction to subgingival de-
treated with ultrasonic instruments and amino acids and              bridement in test sites has shown statistically significant
sodium hyaluronate gel. Mann-Whitney U-test demon-                   reduction of bleeding and probing depth, while no statis-
strated significant differences in pocket depth reduction            tically significant difference between the two treatment
at 45 days (p<0.03) and 90 days (p<0.02) between test                groups was observed regarding plaque index score (PI),




                                                                                                     li
group and control group.                                             clinical attachment level (CAL) and crevicular fluid vol-
                                                                     ume.




                                                                                                  na
Biochemical finding                                                  From a clinical point of view, probing pocket depth and
Gingival crevicular fluid markers                                    bleeding reduction exerts a positive influence in the
Biochemical characteristics of the sites included in the             prognosis of a dental element by decreasing specific risk
study are reported in Table 2.                                       parameters. Nevertheless, amino acids and sodium hy-




                                                                                               io
                                                                     aluronate gel addition could not outcome in a complete
At baseline, statistically significant differences were de-          elimination of periodontal pockets, leading the clinician
tected for the µg/sample of Myeloperoxidase between                  to perform corrective surgical therapy.




                                                                                            az
the two groups (p<0.02). No other differences between                The use of HA has shown statistically significant im-
groups were found.                                                   provement of clinical parameters in the treatment of gin-
                                                                     givitis (15) and accelerates periodontal wound healing
Gingival crevicular fluid volume (GCF)                               (18). Besides, the topical application of hyaluronic acid




                                                                              n
At 1-week, a tendency towards a decrease in GCF                      in combination with non-surgical periodontal treatment
was observed in both groups (test group Tbaseline=74,09              might be useful in reducing bleeding and probing pocket




                                                                           er
(CI: 56,93-91,26) T7 days=32,82 (CI: 23,93-40,71) T45 days           depth, owing to its properties of increasing the extent
=33,38 (CI: 27,58-39,18); control group Tbaseline=70,95              of fibrin polymerization, stabilizing the clot and exerting
(CI: 52,57-89,34) T7 days=34,45 (CI: 27,68-41,23) T45 days           antiexudative activity (34,35).
=38,36 (CI: 30,56-46,17)). Statistical significance was              Conversely, from a biochemical perspective there was

                                                  nt
achieved at re-evaluation at 1-week and at 45 days post-
instrumentation (p<0.001). However, no statistical signif-
icance was found for any re-evaluation for both groups.
                                                                     no evidence for any Aminogam-related difference in cal-
                                                                     protectin levels and peroxidase activity in crevicular fluid.
                                                                     Previous data reported by Engström and colleagues also
                                                iI
                                                                     failed to demonstrate the anti-inflammatory effect of HA in
Calprotectin                                                         relation to immunological (PGE2, IgG, C3) responses in
Significant reductions in µg/sample of calprotectin were             gingival crevicular fluid (9). Gingival crevicular fluid MPO
                                              on

found after 1-week (p<0.01) and an increase at 45 days               and calprotectin are directly related with both the extent
was found in both groups (p<0.01). The concentration of              of polymorphonuclear neutrophils (PMNs) infiltration and
calprotectin elevated after 7 days (p<0.001). There was              the severity of periodontal disease (8). HA modulation of
no evidence for difference for concentrations and in µg/             PMNs function in vitro and in vivo is still controversial,
                                      i


sample between test and control group.                               since both stimulating (36,37,38) and inhibiting activity
                                   iz


                                                                     (39,40) have been reported. Our findings reported that
Myeloperoxidase                                                      concentrations of myeloperoxidase and calprotectin did
Significant reductions in µg/sample of MPO were found                not change during the time of treatment, indicating that
                   Ed




after 1-week (p<0.01) and an increase at 45 days was                 the hyaluronic acid does not significantly affect the activ-
found in both groups (p<0.01). The concentration of                  ity and recruitment of crevicular neutrophils in the inflam-
MPO elevated after 7 and 45 days (p<0.001). There was                matory response as recently reported for human isolated
no evidence for difference for concentrations and in µg/             PMNs exposed to a hyaluronate-carboxymethylcellulose
sample between test and control group.                               membrane (Seprafilm).
 IC




                                                                     Recently it has been reported that hyaluronan plays an
                                                                     important role as moderator of inflammation and it also
Discussion                                                           functions in the negative feedback loop of inflammatory
                                                                     activation, through interacting with fibroblasts’s TSG6
C




The aim of this study was to evaluate whether the appli-             (14). On this basis further investigations should be per-
cation of amino acids and sodium hyaluronate gel could               formed to analyze the effect of hyaluronic acid and ami-
enhance the results obtained by subgingival ultrasonic               no acids on the activity of cells involved in the healing
instrumentation only in patients with chronic periodon-              process, through exploring inflammatory markers, such
©




titis.                                                               as metalloproteinases.
In this study, ultrasonic periodontal debridement with
and without amino acids and sodium hyaluronate gel
resulted in an improvement in all clinical parameters.               Acknowledgements: The authors declare that they have no
These results are consistent with those of Badersten et              conflicts of interests. The study was self-supported by Depart-
colleagues (33) who stated that nonsurgical periodontal              ment of Clinical Medical Sciences, Surgical and Health of Uni-
                                                                     versity of Trieste. Company Errekappa Euroterapici Spa (Milan,
therapy is effective in improving periodontal clinical pa-
                                                                     Italy) provided free materials to be used in the study.
rameters.
In the present investigation, the use of amino acids and

Annali di Stomatologia 2012; III (2): 75-81                                                                                      79
L. Bevilacqua et al.



References                                                           15. Jentsch H, Pomowski R, Kundt G, Göcke R. Treatment of
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                                                                                                     li
    Periodontol 2002; 29 Suppl 3:72-81; discussion 90-1. Re-             Journal of Investigative and Clinical Dentistry 2011; 2(3):
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                                                                                                  na
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                                                                                               io
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                                                                                            az
    chronic periodontitis. J Clin Periodontol 2005 Aug; 32 (8):          planing in the treatment of chronic periodontitis. J Peri-
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                                                                             n
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    calculus. J Periodontol 1990; 61: 3-8.                               noacids combined to sodium hyaluronate (AMINOGAM). J




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Annali di Stomatologia 2012; III (2): 75-81                                                                                             81
