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Oxidative stress is caused by an imbalance between the production of reactive oxygen speos (POS) and a biologio systom's ability to readily detoxify the reactive intermediates. In the periodontium, neutrophil infiltration, fibroblasts, osteoclasts, and endothelial cells, predominantly lead to an increase in the POS lovols, rosulting in broakdown oi epithelial structure and damage to
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Efficacy of Lycopene as a Locally Delivered Gel in Th Etreatment of Chronic Periodontitis
Oxidative stress is caused by an imbalance between the production of reactive oxygen speos (POS) and a biologio systom's ability to readily detoxify the reactive intermediates. In the periodontium, neutrophil infiltration, fibroblasts, osteoclasts, and endothelial cells, predominantly lead to an increase in the POS lovols, rosulting in broakdown oi epithelial structure and damage to
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Oxidative stress is caused by an imbalance between the production of reactive oxygen speos (POS) and a biologio systom's ability to readily detoxify the reactive intermediates. In the periodontium, neutrophil infiltration, fibroblasts, osteoclasts, and endothelial cells, predominantly lead to an increase in the POS lovols, rosulting in broakdown oi epithelial structure and damage to
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Attribution Non-Commercial (BY-NC)
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Als PDF, TXT herunterladen oder online auf Scribd lesen
immune response. 1 There is an increasing body of evidence available to implicate the role of oxidative stress in the pathogen- esis of a variety of inflammatory disorders, including periodontal disease. 1,2 Oxidative stress is caused by an imbalance between the production of reactive oxygen spe- oios (POS) and a biologio systom's ability to readily detoxify the reactive intermedi- ates or easily repair the resulting damage. Mammalian oolls oan gonorato POS by different biologic mechanisms and, in the periodontium, neutrophil infiltration, fibro- blasts, osteoclasts, and endothelial cells, predominantly lead to an increase in the POS lovols, rosulting in broakdown o tno epithelial structure and damage to the con- nective tissue in the near vicinity. 35 Smoking is an indopondont risk aotor and is known to navo a signiioant ooot on the initiation, extent, and progression Periodontal diseases are inflammatory dis- orders that give rise to tissue damage and loss as a result of complex interactions between pathogenic bacteria and the hosts 1 Reader, Department of Periodontics, SVS Institute of Dental Sciences, Mahabubnagar, Andhra Pradesh, India. 2 Senior Lecturer, Department of Periodontics, Gitam Dental College and Hospital, Visakhapatnam, Andhra Pradesh, India. 3 Senior Lecturer, Department of Public Health Dentistry, SVS Institute of Dental Sciences, Mahabubnagar, Andhra Pradesh, India. 4 Senior Lecturer, Department of Periodontics, SVS Institute of Dental Sciences, Mahabubnagar, Andhra Pradesh, India. 5 Professor, Department of Periodontics, SVS Institute of Dental Sciences, Mahabubnagar, Andhra Pradesh, India. 6 Professor, Department of Periodontics, Gitam Dental College and Hospital, Visakhapatnam, Andhra Pradesh, India. Correspondence: Dr Rampalli Viswa Chandra, Department of Periodontics, SVS Institute of Dental Sciences, Mahabubnagar, Andhra Pradesh, India. Email: viswachandra@hotmail.com Effcacy of lycopene as a locally delivered gel in the treatment of chronic periodontitis: Smokers vs nonsmokers Pampalli viswa Cnandra, MDS 1 /Yollartni P. Sandnya, MDS 2 / Sripriya Nagara|an, MDS 3 /Bavigadda Harisn Poddy, MDS 4 / Anumala Navoon, MDS 5 /K. Pa|a v. Murtny, MDS 6 Objective: The present study was carried out as a multicenter, randomized controlled, split-mouth clinical trial to evaluate the efficacy of locally delivered lycopene on periodontal noaltn and gingival orovioular luid (GCF) lovols o 8-nydroxydooxyguanosino (8-OHdG) in smokors and nonsmokors oomparod witn poriodontally noaltny oontrol sub|oots. Method and Materials: Ono nundrod ton sub|oots inoluding 50 smokors, 50 nonsmokors, and 10 oontrols partioipatod in tnis study. Sub|oots in tno smokor and nonsmokor groups nad oontralatoral sitos troatod witn lyoopono gol and a plaoobo. Clinioal paramotors included recording site-specific measures of plaque, gingivitis, probing depth, and clinical attaonmont lovol. GCF 8-OHdG valuos woro analyzod using a oommoroially availablo ELSA kit. Results: Comparod witn tno plaoobo, lyoopono-troatod sitos in smokors and nonsmokors snowod signiioant roduotions in probing doptns and gain in tno olinioal attaonmont lovols. Howovor, tnoro was no statistioally signiioant dioronoo in tno olinioal paramotors wnon lyoopono-troatod sitos in smokors and nonsmokors woro oomparod, oxoopt or tno roduotion in tno 8-OHdG lovols. Tno 8-OHdG lovols at 1 wook and 3 montns in sitos troatod witn lyoopono in tno smokor and nonsmokor group woro oomparablo witn those in the periodontally healthy control group. Conclusion: The gel formulation was effective in increasing clinical attachment and reducing gingival inflammation, probing doptn, and oxidativo in|ury oomparod witn tno plaoobo in smoking and nonsmoking sub|oots. (Quintessence Int 2012;43:401411.) Key words: antioxidants, lyoopono, poriodontitis, smoking 402 VOLUME 43 NUMBEP 5 MAY 2012 QUI NTESSENCE I NTERNATI ONAL Chandra et al of periodontal disease. The immunosup- prossivo ooots o smoking, 6 along with its ability to selectively alter the subgingival environment, allowing the overgrowth of periodontopathic bacteria, are well docu- mented. 7 Wnilo tobaooo smoko in itsol is a source of free radicals, 8 nicotine, the main oomponont o tobaooo smoko, nas tno potontial to innibit noutropnil POS roloaso in low doses, impairing the elimination of peri- odontal pathogens. 9 In high doses, nicotine aotually stimulatos POS roloaso tnat oausos oxidative stress-mediated tissue damage in the gingivoperiodontal tissues. 8,9
Tno ooots o POS aro gonorally nogat- ed by a complex system of antioxidants, suon as glutatniono, vitamin C, and vitamin E, as well as enzymes such as catalase, suporoxido dismutaso (SOD), and various peroxidases. 5 Howovor, smokors also oxpo- rience a decrease in the serum concentra- tions o ma|or oiroulating antioxidants duo to tno obligatory uso o tno body's rosorvo of antioxidants to detoxify the unusually high levels of these free radicals in tobacco smoko. 10,11 Diroot oral supplomontation o antioxidant onzymos suon as SOD and glutathione peroxidase is impractical since they are readily prone to inactivation by gastric secretions, 12 thus necessitating the use of extraneous antioxidant supplements. Antioxidant supplementation has the potential to decrease damage because of oxidative stress, and purified lycopene prep- arations have been shown to decrease oxida- tive damage and reduce the concentrations o various markors o oxidativo stross suon as 8-nydroxydooxyguanosino (8-OHdG). 13
8-OHdG is tno bost-dooumontod biomarkor of oxidative stress, which is involved in the instigation of various diseases, including periodontitis. 14 An inoroaso in 8-OHdG oan be considered a sign of periodontal dam- age, 3 and the subsequent posttreatment decrease in its levels has been well dem- onstrated in periodontitis, thus reflecting the status of periodontal health. 4 Sinoo smoking oan signiioantly inoroaso sorum 8-OHdG lovols, 8-OHdG is oonsidorod a usoul bio- markor o oxidativo oonditions, inoluding poriodontitis, aootod by smoking. 15 While the effect of systemically admin- istered lycopene on gingivitis has been investigated, 1 the authors are not aware of published data on the use of a locally deliv- ered lycopene in the treatment of periodon- titis. The present study has been carried out as a multicenter, randomized controlled clinical trial to evaluate the efficacy of a locally delivered antioxidant gel on peri- odontal health and gingival crevicular fluid (GCF) lovols o 8-OHdG in smokors and nonsmokors oomparod witn tno poriodon- tally healthy control group. METHOD AND MATERIALS Source of data A total of 110 systemically healthy male sub- |oots solootod rom tno outpationt sootion o tno Dopartmont o Poriodontios, in tno par- tioipating institutions (SvS nstituto o Dontal Soionoos, Manabubnagar, Andnra Pradosn, ndia, and Gitam Dontal Collogo and Hospital, visaknapatnam, Andnra Pradosn, ndia) botwoon January 2010 and Fobruary 2011 were divided into three groups. The smokor group (n = 50) inoludod sub|oots between the ages of 25 and 50 years pre- senting with a minimum of four periodontal pookots witn probing doptn . 5 mm and a nistory o oigarotto smoking . 10 cigarettes a day for a minimum of 5 years. Individuals in tno smokor group woro drawn rom a pool of patients who persistently refused to partioipato in a smoking-oossation program oorod to tnom roo o oost. Tno nonsmokor group (n = 50) oomprisod systomioally noaltny sub|oots botwoon tno agos o 25 and 50 years with a history of chronic peri- odontitis presenting with a minimum of four poriodontal pookots witn probing doptns . 5 mm. To assoss 8-OHdG lovols in pori- odontally healthy individuals, 10 systemi- oally noaltny sub|oots botwoon tno agos o 25 and 50 years with clinically healthy peri- odontium acted as negative controls and received no treatment apart from meticulous plaque control instructions. To exclude the possibility o poriodontal disoaso, sub|oots in this group underwent a six-point probing in all tno tootn. Padiograpns woro takon at suspect sites to rule out periodontal dis- oaso. Tno ollowing sub|oots woro oxoludod: medically compromised patients, patients receiving any form of periodontal therapy VOLUME 43 NUMBEP 5 MAY 2012 403 QUI NTESSENCE I NTERNATI ONAL Chandra et al (surgioal or nonsurgioal), tnoso wno nad received antibiotic or antioxidant therapy within 6 months of baseline examination, patients who had used antibacterial mouth- wash or medicated toothpaste within the past month of baseline examination, and patients with a history of deleterious habits. All patients gave informed consent, and the study protocol was explained in the local language. Ethical clearance for the study was received from the ethical committees of the participating institutions (approval no. 17-1209SvS and 10897). Clinioal paramotors inoludod rooord- ing noninvasive site-specific measures of plaquo (Plaquo ndox |P]) 16 and gingivitis (modiiod Gingival ndox |MG]) 17 at base- line and 1, 3, and 6 months. Probing depth (PD) and olinioal attaonmont lovol (CAL) were recorded at baseline (before scaling and root planing) and at 3 and 6 montns. A oustom-mado aorylio stont and a UNC no. 15 color-coded periodontal probe were used to standardize the measurement of sito-spooiio PD and CAL. Sample size Tno primary outoomo, gain in tno CAL, was selected as the critical variable to calculate tno samplo sizo. Fity pationts (100 in total) in tno smokor and nonsmokor groups woro roquirod to navo an 80% onanoo o dotooting as signiioant (at tno two-sidod 5% lovol) a 1% dioronoo botwoon tno two groups in tno moan CAL, witn assumod standard doviation o 2.5, and a plannod 15% rato o missing patients on follow-up. An additional 10 sub- |oots woro usod as nogativo oontrols or oom- parison o 8-OHdG lovols witn tno smokor and nonsmokor groups or gaining additional information on the treatment effects. Thus, the inal samplo sizo inoludod 110 sub|oots. Randomization and blinding Pandomization and blinding inoludod computerized generation of the allocation soquonoo in random pormutod blooks as dosoribod by Sagnaoi 18 and blinded dis- bursement of medication. The medication was plaood by tnroo invostigators (P.v.C., B.H.P., and Y.P.S.) in oontralatoral sitos, whereas the relevant readings were record- od by two oalibratod invostigators (A.N. and K.P.v.M.), all o wnom woro blindod to tno group (smokors/nonsmokors) and to tno nature of drug placed at the site (lycopene/ plaoobo). Tno blinding was not brokon until this clinical trial was completely finished. Reproducibility Inter- and intraexaminer reliability was test- od using kappa statistios. Duplioato olinioal oxaminations o 20% o tno sub|oots yioldod kappa statistios o 94%, 92%, 93%, and 97% or PD, CAL, P, and MG, rospootivoly, indicating good intraexaminer agreement. Interexaminer results showed an agreement o 85% and 90% or PD and CAL and 82% and 86% or P and MG, rospootivoly. Ineligible subjects Four pationts (two in tno smokor group and two in tno nonsmokor group) woro excluded from the analysis because they were found to be ineligible after randomiza- tion. The reasons for ineligibility included inoorroot diagnosis (ono pationt), rousal to partioipato in tno study (two pationts), and rousal o tnorapy (ono pationt). Tnorooro, data analysis was restricted to 106 eligible pationts (smokors |n = 48], nonsmokors |n = 48], and oontrols |n = 10]). Preparation of the 2% lycopene gel Lyoopono (BS CHEME ntornational) was dissolved in a solvent mixture (ethanol, propylene glycol, and water in the ratio o 50:30:20). Tno pH o tnis mixturo was ad|ustod to 7.4 witn triotnanolamino. Tno solution was tnon gollod by adding 8% nydroxypropyloolluloso (HPC) and sot asido for 24 hours. The in situ gel was prepared to tno oonoontration o approximatoly 2%. Tno drug was extensively evaluated for drug content, viscosity determination, in vitro permeation, and stability. The spectropho- tometric method reported by Patel et al 19
was modified for the in vitro estimation of the rate of drug release. The in vitro release profile showed an initial burst release for the first 24 hours followed by controlled release of lycopene for up to 120 hours. The pla- cebo was prepared in the same manner but witnout tno aotivo drug. Tnus, ovory sub|oot in botn tno smokor and nonsmokor groups nad a sito troatod witn lyoopono gol (L) and a plaoobo (P). Drugs L and P woro indistin- guishable based on appearance. 404 VOLUME 43 NUMBEP 5 MAY 2012 QUI NTESSENCE I NTERNATI ONAL Chandra et al Local drug delivery Soaling and root planing was porormod at baseline by using a piezoelectric ultrasonic scaling unit under water spray at a medi- um powor sotting and a 4P/4L Columbia University curette until the root surface was considered smooth and clean by the operators. After scaling and root planing, contralateral sites with the deepest probing depths were selected, and a standardized quantity o 0.1 mL o tno gol (2 mg/0.1 mL) and the placebo was delivered using a specially modified insulin delivery syringe with a blunt-end precision tip
(Colo-Palmor) (Fig 1). For tno purposo o maintaining standardization, interdental suprabony poriodontal pookots in molars witn probing depths greater than 5 mm were selected for looal drug dolivory. Sub|oots woro instruot- ed to refrain from aggressively chewing, rinsing, and brushing the test sites for a poriod o 1 wook. Cnlornoxidino gauzo pads
(Baotisao, Anasuya Surgioals) woro providod to all tno sub|oots to wipo tno tost sites to affect a palliative plaque control rogimon. Sub|oots woro askod to roport any possible adverse effects or unusual symp- toms during the study period. In addition, the periodontally affected sites in quad- rants not involved in the study received periodontal maintenance care, and addi- tional nonsurgical or surgical treatment, if required, was instituted after determining the response to initial therapy. Collection of GCF samples GCF sampling was porormod at tno tost and control sites immediately after scaling and root planing and before placement o tno gol. n tno oontrol group, GCF was collected from the maxillary right central incisor area in all the patients. After isola- tion, 0.6-mm filter paper
(Wnatman) circles were used for collecting the samples by the intracrevicular method. The fluid seeping out of the sulcus was collected, and any paper contaminated with blood or saliva was discarded. The collection was repeat- ed after 30 minutes. The strip was left for 30 seconds and then immediately immersed in 100 L o distillod wator. Samplos woro storod at 30C and assayod on tno day o collection. Determination of GCF 8-OHdG by ELISA GCF samplos woro oontriugod at 10,000 g for 10 minutes, and the supernatant was usod to dotormino 8-OHdG lovols witn a oommoroially availablo ELSA kit (Hignly Sonsitivo 8-OHdG Cnook). Tno valuos woro takon at basolino, 1 wook, and 3 montns. Fig 1 Lycopene gel being delivered into a peri- odontal pocket using a specially modifed insulin delivery syringe with a blunt-end precision tip. VOLUME 43 NUMBEP 5 MAY 2012 405 QUI NTESSENCE I NTERNATI ONAL Chandra et al Statistical analysis The intended primary outcome of the study was gain in tno CAL. Tno sooondary out- oomos inoludod roduotion in tno PD, MG, P, and 8-OHdG lovols. ntragroup oomparison o PD, CAL, P, MG, and 8-OHdG lovols botwoon tno vari- ous groups was performed using repeated moasuros analysis o varianoo (ANOvA) followed by multiple comparison using Bonorroni oorrootion. Unpairod t test was used for intergroup comparison of the vari- ables. A P value of < .01 was considered statistioally signiioant. Data woro analyzod using a commercially available software program
(SPSS 17.0, BM) RESULTS n tno smokor group (n = 48, oigarottos por day, 18.10 4.33), tno moan ago o tno sub|oots was 29.80 5.63 yoars. n tno non- smokor group (n = 48), tno moan ago o tno sub|oots was 33.90 7.66 yoars. Tno moan ago o tno oontrols (n = 10) was 30.10 2.25 years. ntragroup oomparison o PD and CAL at baseline and 3 and 6 months showed a statistically significant reduction in mean sooros in smokors (lyoopono and plaoobo groups) and nonsmokors (lyoopono and plaoobo groups) (P < .01) witn tno di- ferences being more significant from the basolino to 3 and 6 montns. Howovor, tno dooroaso in PD and CAL gain among tno control group was not statistically signifi- cant (P > .01) (Tablo 1). Intragroup comparison of PI and MGI at baseline and 1, 3, and 6 months showed a statistically significant reduction in mean plaquo and gingival sooros in smokors (lyoopono and plaoobo groups) and non- smokors (lyoopono and plaoobo groups) (P < .01), witn tno dioronoos boing moro significant from the baseline to 3 and 6 months. In the control group, there was a statistically significant decrease in the plaque scores but not for the gingival sooros (Tablo 2). ntragroup oomparison o 8-OHdG lovols at basolino, 1 wook, and 3 montns showed a statistically significant decrease in moan 8-OHdG sooros in smokors (lyoo- pono and plaoobo groups) and nonsmokors (lyoopono and plaoobo groups) (P < .01), with the differences being more significant rom basolino to 1 wook and 3 montns. Tno mean decrease was not statistically signifi- cant (P > .01) in tno oontrol group (Tablo 3). Table 1 Intragroup comparision of PD and CAL among smokers, nonsmokers, and controls PD (mean SD) CAL (mean SD) Group Baseline 3 mo 6 mo Baseline 3 mo 6 mo Smokers Lycopene 6.21 1.29 3.25 1.02* 3.50 0.92* 6.30 1.25 4.20 1.39* 4.11 1.19* F = 131.2 P = .000 F = 28.34 P = .000 Placebo 6.02 1.49 5.20 1.70* 5.16 1.52* 6.20 1.22 5.10 0.99 5.41 1.07 F = 15.00 P = .000 F = 5.36 P = .000 Nonsmokers Lycopene 6.04 0.87 4.00 0.58* 3.95 1.21* 6.40 1.89 4.30 1.41* 4.30 1.41* F = 84.05 P = .000 F = 10.20 P = .000 Placebo 6.31 1.27 4.87 2.00* 4.81 1.34* 6.20 1.22 5.00 1.05* 4.80 1.13* F = 33.88 P = .000 F = 8.23 P = .000 Controls 1.03 0.27 1.12 0.30 1.10 0.31 0.63 0.23 0.59 0.17 0.60 0.20 F = 0.35 P = .28 F = 0.54 P = .58 Comparison o moans using ANOvA. * Signiioant as oomparod witn tno basolino using a multiplo oomparison tost. PD, probing doptn, CAL, olinioal attaonmont lovol, SD, standard doviation. 406 VOLUME 43 NUMBEP 5 MAY 2012 QUI NTESSENCE I NTERNATI ONAL Chandra et al ntorgroup oomparison o PD, CAL, P, MG, and 8-OHdG lovols botwoon lyoopono and plaoobo in smokors and nonsmokors showed a statistically significant decrease in moans or PD and CAL gain at 3 and 6 montns and a dooroaso in tno 8-OHdG lovols at 1 wook and 3 montns in tno lyoo- pene group. The plaque scores and gingi- val scores, however, were not significant (Tablo 4). Comparison o PD, CAL, P, MG, and 8-OHdG lovols botwoon smokors and nonsmokors in tno lyoopono and plaoobo groups showed no significant differences between the two groups (P > .01) or all variables, except for the reduction in tno 8-OHdG lovols, wnion was statistioally signiioant at 1 wook and 3 montns in non- smokors wnon oomparod to smokors in tno lycopene group (P < .01) (Tablo 5). Comparision o tno oontrol group 8-OHdG lovols witn sitos troatod witn lyoo- pono in smokors and nonsmokors snowod a statistically significant difference in the sooros at basolino in botn smokors and nonsmokors, wnion booamo nonsignii- Table 3 Intragroup comparision of 8-OHdG levels (in ng/mL) among smokers, nonsmokers, and controls 8-OHdG levels (mean SD) Group Baseline 1 wk 3 mo Smokers Lycopene 5.67 1.51 1.28 0.22* 1.35 0.19* F = 95.6 P = .000 Placebo 5.66 1.52 1.73 0.34* 1.46 0.26* F = 84.7 P = .000 Nonsmokers Lycopene 5.34 1.14 1.04 0.32* 1.11 0.28* F = 170.37 P = .000 Placebo 5.43 1.14 1.51 0.81* 1.49 0.25* F = 107.36 P = .000 Control 1.65 0.16 1.38 0.20 1.30 0.17 F = 9.19 P = .14 Comparison o moans using ANOvA. *Signiioant as oomparod witn tno basolino using a multiplo oomparison tost. 8-OHdG, 8-nydroxydooxyguanosino, SD, standard doviation. Table 2 Intragroup comparision of PI and MGI among smokers, nonsmokers, and controls PI (mean SD) MGI (mean SD) Group Baseline 1 mo 3 mo 6 mo Baseline 1 mo 3 mo 6 mo Smokers Lycopene 3.51 0.67 2.69 0.68 1.89 0.60* 1.80 0.55* 2.66 0.44 1.86 0.53 0.76 0.50* 0.75 0.50* F = 21.02 P = .000 F = 38.87 P = .000 Placebo 3.59 0.68 2.78 0.68 2.05 0.76 1.84 0.57* 2.75 0.45 1.88 0.54 0.78 0.51* 0.82 0.54* F = 17.27 P = .000 F = 37.52 P = .000 Nonsmokers Lycopene 3.44 0.62 2.57 0.81 1.80 0.55* 1.55 0.63* 2.71 0.45 1.85 0.53 0.67 0.38 0.77 0.51 F = 20.60 P = .000 F = 44.34 P = .000 Placebo 3.52 0.66 2.57 0.81 1.50 0.58 1.63 0.55* 2.80 0.43 1.85 0.53 0.71 0.44 0.86 0.66 F =23.50 P = .000 F = 36.05 P = .000 Control 1.05 0.23 0.69 0.26 0.54 0.21* 0.52 0.25* 0.63 0.19 0.50 0.18 0.52 0.27 0.56 0.19 F = 18.67 P = .000 F = 1.52 P = .24 Comparison o moans using ANOvA. *Signiioant as oomparod witn tno basolino using a multiplo oomparison tost. P, Plaquo ndox, MG, modiiod Gingival ndox, SD, standard doviation. VOLUME 43 NUMBEP 5 MAY 2012 407 QUI NTESSENCE I NTERNATI ONAL Chandra et al Table 4 Intergroup comparision of PD, CAL, PI, MGI, and 8-OHdG levels between lycopene and placebo groups of smokers and nonsmokers Smokers (lycopene vs placebo) Nonsmokers (lycopene vs placebo) t P value t P value PD Basolino 3 mo 6 mo 0.69 6.84 6.49 .49 .000 .000 1.21 2.90 3.25 .22 .005 .002 CAL Basolino 3 mo 6 mo 0.85 0.10 0.02 .65 .000 .000 0.06 4.05 3.66 .94 .000 .000 PI Basolino 1 mo 3 mo 6 mo 0.82 0.63 0.24 0.70 .65 .50 .03 .85 1.07 0.07 3.18 0.98 .28 .94 .15 .43 MGI Basolino 1 mo 3 mo 6 months 0.54 0.39 0.63 0.07 .36 .77 .79 .43 1.70 3.95 4.08 0.30 .44 > .999 .48 .53 8-OHdG Basolino 1 wk 3 mo 0.29 0.02 0.23 .67 .000 .000 5.78 1.43 2.83 .92 .000 .000 PD, probing doptn, CAL, olinioal attaonmont lovol, P, Plaquo ndox, MG, modiiod Gingival ndox, 8-OHdG, 8-nydroxydooxyguanosino. Table 5 Intergroup comparision of PD, CAL, PI, MGI, and 8-OHdG levels between smokers and nonsmokers in lycopene and placebo groups Lycopene (smokers vs nonsmokers) Placebo (smokers vs nonsmokers) t P value t P value PD Basolino 3 mo 6 mo 0.80 4.41 2.07 .42 .18 .04 1.02 0.87 1.20 .30 .38 .23 CAL Basolino 3 mo 6 mo 0.27 0.61 0.35 .78 .53 .72 0.22 1.91 3.21 .82 .05 .34 PI Basolino 1 mo 3 mo 6 mo 1.15 0.85 0.74 0.90 .25 .39 .45 .37 0.56 1.42 2.50 0.35 .57 .15 .11 .72 MGI Basolino 1 mo 3 mo 6 mo 0.63 0.43 0.61 0.20 .53 .66 .54 .83 0.51 0.74 0.18 0.08 .60 .45 .85 .93 8-OHdG Basolino 1 wk 3 mo 1.77 3.77 4.16 .07 .000 .000 1.90 1.12 0.77 .13 .26 .43 PD, probing doptn, CAL, olinioal attaonmont lovol, P, Plaquo ndox, MG, modiiod Gingival ndox, 8-OHdG, 8-nydroxydooxyguanosino. oant at 1 wook and 3 montns. A statisti- cally significant difference in the mean valuos botwoon oontrol vs smokors and non- smokors in plaoobo-troatod sitos was soon at all three time-bound intervals (P < .01) (Tablo 6). 408 VOLUME 43 NUMBEP 5 MAY 2012 QUI NTESSENCE I NTERNATI ONAL Chandra et al DISCUSSION There seems to be an increasing volume of evidence on the association between oxida- tive stress and periodontitis. 20 Niootino, tno main oomponont o tobaooo smoko, nas tno potontial to stimulato POS roloaso, wnion causes oxidative stress-induced tissue damage in the gingivoperiodontal tissues. 9
At the tissue level, the effects of nicotine on the human periodontal ligament fibroblasts is woll-known, 21 and a recent study has demonstrated that treatment with antioxi- dant combinations counteracted the effects of nicotine by restoring and increasing the cell-migration rates of oral fibroblasts. 22 Mediators of oxidative damage such as malondialdonydo (MDA) and SOD aro increased in periodontitis, but most impor- tantly, nonsurgical periodontal therapy can rostoro and oontrol tno sub|oot antioxidant capacity by locally and systemically modify- ing tno lovols o MDA, SOD, and total oxida- tivo status (TOS) in poriodontal tissuo. 23 Lycopene exhibits the highest physical quenching rate with singlet oxygen 24 and is at least three times more effective than beta carotene in preventing cell death by quononing NOO - radicals. 25 It also reverses DNA damago induood by nydrogon porox- ide. . 26
A study investigated the relationship between monthly tomato consumption and serum lycopene levels in congestive heart ailuro (CHF) individuals witn poriodontitis and concluded that a relationship exists botwoon poriodontitis and CHF risk, and monthly tomato consumption appears to affect this relationship in a positive direction in poriodontitis sub|oots. 27 Lycopene, commonly delivered as a gel, snows aoooptablo kinotios in tno numan oral mucosal surfaces. 28 This drug reach- os a poak oonoontration witnin 15 to 36 hours and returns to the baseline levels witnin approximatoly 80 to 104 nours. 29 The vehicle used in this study, hydroxypropyl oolluloso (HPC), is a oolluloso dorivativo that demonstrates both water and organic solubility. HPC is a biodogradablo muoo- adhesive gel used to administer a vari- ety of compounds including antibiotics, 30
antiseptics, 31 and growth factors. 32 The experimental gel showed good biologic acceptability, and no evidence of burning sensation, abscess formation, suppuration, or staining was found. While any antioxidant can theoretically be used, we chose lycopene because its levels are relatively constant and not vulner- ablo to postsmoking doplotion as soon witn other antioxidants. 11 Lycopene also demon- strates intriguing nonantioxidant functions such as reduction in the oxidative state of macrophages and inhibition of choles- terol synthesis secondary to the inhibition o oollular nydroxy-3-motnylglutaryl-CoA (HMGCoA) roduotaso. 33 The latter mecha- nism is known to navo bonoioial ooots on alveolar bone loss and tooth mobility in sub|oots witn poriodontal disoaso. 34 To tno bost o our knowlodgo, tnoro have been no studies evaluating the effi- oaoy o 2% lyoopono gol in onronio pori- odontitis, nonoo, a diroot oomparison witn other studies is not possible. The effect of systemically administered lycopene as monotnorapy and as an ad|unot to soaling and root planing in gingivitis patients has Table 6 8-OHdG levels of control group compared with smokers and nonsmokers Baseline 1 wk 3 mo Groups t P value t P value t P value Control vs smokors (L) 8.56 .00 0.72 .46 0.87 .29 Control vs smokors (P) 9.28 .00 4.18 .00 2.01 .00 Control vs nonsmokors (L) 11.10 .00 2.60 .12 0.78 .12 Control vs nonsmokors (P) 11.52 .00 1.29 .00 2.70 .01 L, lyoopono, P, plaoobo. VOLUME 43 NUMBEP 5 MAY 2012 409 QUI NTESSENCE I NTERNATI ONAL Chandra et al been reported, with the authors reporting statistically significant reductions in gingi- vitis and gingival bleeding. 1 In this study, better response to lycopene was observed in sub|oots witn doplotod lovols o salivary antioxidants. 1 There is a paucity of research on the effects of antioxidant gels in peri- odontitis sub|oots. Provious studios did not support the use of vitamin E gel 35 or vita- min C supplomontation 36 for the control of gingivitis or poriodontal disoaso. Howovor, in one clinical study, gingival bleeding increased significantly after a period of vita- min C doplotion and roturnod to basolino valuos ator vitamin C roplotion. 37 Nonsmokors witn poriodontitis domon- stratod nignor 8-OHdG valuos tnan oon- trols, as reported in previous studies, 4,15,38
and smokors domonstratod nignor 8-OHdG valuos tnan nonsmokors, wnion is in agroo- ment with most previous studies. 9,15,21,39 As ovidonood by tno initial 8-OHdG lovols, tno greater efficacy of lycopene can be attrib- uted to the lower oxidative stress seen in nonsmokors oomparod witn smokors. 9,15,21,39
Analysis o tno 8-OHdG lovols botwoon 1 wook and 3 montns sooms to suggost tnat lycopene exerts its maximum effect within tno irst wook and is ablo to maintain its therapeutic action for longer periods of timo. Tno 2% gol oan bo omployod or oon- trolled delivery of lycopene for 7 days in the subgingival area. From tno data oomparing tno 8-OHdG lov- els of the two groups with the control group, it can be inferred that a single-dose administra- tion of lycopene can elicit significant reduc- tion in tno 8-OHdG lovols and nas tno ability to decrease antioxidant damage to a level seen in healthy tissues to confer a protective effect on the periodontal tissues. Though not to the same degree as lycopene, placebo- treated sites also demonstrated a significant roduotion in 8-OHdG lovols, tnougn tnis could be due to the effects of scaling and root planing, which has been shown to con- tribute to a reduction in oxidative stress. 4,40
In the present study, the reduction in the oxidativo stross in smokors and nonsmokors was rolootod by gain in CAL and roduotion in PD. Tno rosults o tno ourront study aro in agreement with previous studies in which the subsequent posttreatment decrease in 8-OHdG lovols nas boon assooiatod witn gains in tno CAL and PD roduotion. 24 When compared with the placebo, lycopene-treat- ed sites showed a significant reduction in probing depths and attachment loss levels in botn tno smokor and nonsmokor groups, but the same was not seen in the plaque and gingival scores. In contrast to our findings, studies in which antioxidants have been administered systemically over a short dura- tion have reported a statistically significant reduction in gingivitis and bleeding index scores but were not effective in reducing lovols o plaquo aooumulation and PD. 1,37 Howovor, no signiioant dioronoo was observed in the clinical parameters between the lycopene-treated sites in the smokor and nonsmokor groups, oxoopt or tno 8-OHdG lovols. Smoking oausos doplo- tion of systemic endogenous antioxidant capacity, resulting in increased pro-oxidant burden and tissue damage 5 and delivering a supplemental antioxidant that in this study might have contributed to the decrease in PD and CAL gain in botn tno groups. Howovor, smoking is also known to lowor plasma concentrations of endogenous and supplemental carotenoids, 21 but with lyco- pono, tnoro is ovidonoo tnat smoking status is not inversely related to circulating con- centrations of lycopene in humans. 41 We did find a small nonsignificant increase in tno 8-OHdG lovols rom 1 wook to 3 montns in lycopene-treated sites, which is probably indicative of decreasing lycopene action. Howovor, markors o antioxidant damago as in this study need not accurately reflect the overall antioxidant status of a patient. 42
The study results can be further validated through tests such as the total antioxidant oapaoity (TAC), wnoroin tno ull spootrum o antioxidant activity against various reactive oxygen radicals can be assessed. 43
It is an established fact that individuals smoko oigarottos diorontly rom ono anotnor and may absorb different amounts of nicotine, ovon wnon smoking oigarottos o tno samo brand. 44 n tnis situation, ovaluation o smok- ers based on their serum cotinine levels rath- er than self-reported use can investigate the effects of antioxidant therapy more accurately tnan sol-roporting by tno sub|oots. 44 Women were not evaluated partly because of their low prevalence 5 and partly because estrogen- induood proinlammatory oytokinos, suon as 410 VOLUME 43 NUMBEP 5 MAY 2012 QUI NTESSENCE I NTERNATI ONAL Chandra et al intorloukin 1 bota and tumor noorosis aotor oan also gonorato POS during monstruation and at monopauso, tnus aooting 8-OHdG levels. 45 Another limitation of this study is that we have considered only heavy 46 smokors, tno inolusion o lignt smokors witn varying degrees of periodontitis can be considered in future studies. CONCLUSION The lycopene gel formulation was effec- tive in increasing clinical attachment and in roduoing gingival inlammation, PD, and oxidativo in|ury in smoking and nonsmok- ing sub|oots. n a pationt wno is a smokor, tno primary oous is on oossation. But ovon with the most dedicated tobacco-cessation programs, the relapse rate can be as high as 23%. 47 n smokors unwilling to ooaso smok- ing or oonsidoring |oining a tobaooo-oossa- tion program, the feasibility of using a locally dolivorod antioxidant gol as an ad|unot to mechanotherapy, especially during the main- tenance phase, merits further studies. ACKNOWLEDGMENTS This study received no external support, but was fund- ed by the authors institutions. The authors declare no potential conficts of interests. The authors thank Dr G Sudhir for the ELISA analysis of 8-OHdG and Ms V Surekha for the preparation and evaluation of lyco- pene and placebo gels. REFERENCES 1. Chandra RV, Prabhuji ML, Roopa DA, Ravirajan S, Kishore HC. 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