Home Print this page Email this page
Users Online: 288
Home About us Editorial board Search Ahead of print Current issue Archives Submit article Instructions Subscribe Contacts Login 

 Table of Contents  
ORIGINAL ARTICLE
Year : 2014  |  Volume : 5  |  Issue : 3  |  Page : 112-118

Comparative evaluation of amoxicillin plus metronidazole and doxycycline alone in the nonsurgical treatment of localized aggressive periodontitis


1 Department of Periodontics, Sree Sai Dental College and Research Institute, Srikakulam, India
2 Department of Periodontics, Rama Dental College and Hospital, Kanpur, Uttar Pradesh, India
3 Department of Periodontics, Government Dental College and Hospital, Vijayawada, India
4 Department of Periodontics, Mamata Dental College, Khammam, India
5 Department of Periodontics, MN Raju Dental College and Hospital, Sangareddy, Andhra Pradesh, India

Date of Submission27-Jun-2013
Date of Acceptance12-May-2014
Date of Web Publication12-Nov-2014

Correspondence Address:
Rajasekhar Nutalapati
Department of Periodontics, Sree Sai Dental College and Research Institute, Srikakulam, Andhra Pradesh
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0976-6944.144514

Rights and Permissions
  Abstract 

Aim and Objective: To evaluate the effects of a combination of amoxicillin plus metronidazole and doxycycline alone in the nonsurgical treatment of localized aggressive periodontitis (LAP) and compare their effects on clinical and microbiological parameters during 90 days followup in patients with LAP.
Materials and Methods:
A total of 20 patients with LAP were included in the study. Collection of subgingival plaque samples and recordings of clinical parameters, that is, plaque index (PI), gingival index (GI), probing pocket depth (PPD), and clinical attachment loss (CAL) was done at baseline. The subjects were randomly divided into two groups. Group I subjects were given a combination of amoxicillin plus metronidazole and Group II subjects were given doxycycline. Full-mouth scaling and root planing (SRP) was performed at day 10. Collection of subgingival plaque samples and recording of clinical parameters was repeated at days 10, 30, and 90.
Results:
There was a statistically highly significant difference (P < 0.001) for both Group I and Group II at baseline and days 10, 30, and 90 for all the clinical parameters. With respect to PI and GI, there was a statistically significant difference in Group I at days 30 and 90 (P < 0.05) compared to Group II. For the PPD and CAL, there was a statistically significant difference in Group I at days 10, 30, and 90, (P < 0.05) compared to Group II.
Conclusion: Systemic administration of doxycycline with full mouth SRP resulted in a better improvement of periodontal parameters and elimination/suppression of putative periodontal pathogens such as Aa, Pg, and Tf, than amoxicillin plus metronidazole in patients with LAP.

Keywords: Amoxicillin, chemotherapy, doxycycline, localized aggressive periodontitis, metronidazole, microbiology


How to cite this article:
Nutalapati R, Kasagani SK, Jampani ND, Mutthineni RB, Chintala S, Kode VS. Comparative evaluation of amoxicillin plus metronidazole and doxycycline alone in the nonsurgical treatment of localized aggressive periodontitis . Indian J Oral Sci 2014;5:112-8

How to cite this URL:
Nutalapati R, Kasagani SK, Jampani ND, Mutthineni RB, Chintala S, Kode VS. Comparative evaluation of amoxicillin plus metronidazole and doxycycline alone in the nonsurgical treatment of localized aggressive periodontitis . Indian J Oral Sci [serial online] 2014 [cited 2019 Jul 22];5:112-8. Available from: http://www.indjos.com/text.asp?2014/5/3/112/144514


  Introduction Top


Localized aggressive periodontitis (LAP) has been identified as a different disease entity, and results of clinical and microbiologic studies show that it has a complex etiology and pathogenesis in periodontal destruction. [1],[2] Since the disease is characterized by a rapid destruction pattern, different treatment modalities besides conventional periodontal treatment are used. [3] The unique subgingival microflora of disease is one of the most important reasons for periodontal destruction. [4],[5] Preliminary studies on the subgingival flora of patients with LAP demonstrate that Porphyromonas gingivalis (Pg) and Aggregatibacter actinomycetemcomitans (Aa) are the most encountered microorganisms in these patients. [6] Research studies on the microbiota of LAP patients reveal the presence of Aa and demonstrate that this organism plays a significant role in the etiology and the progression of the disease. [7],[8]

In periodontal infections and elsewhere, polymorphonuclear leukocytes (PMNs) migrate to the infection site, phagocytose the bacteria, and attempt to kill them with reactive oxygen metabolites and microbicidal proteins. [9] Although PMNs are highly effective in defending against bacterial infections, some pathogens are difficult to kill. For example, Aa resists phagocytic killing by PMNs. [10],[11] The oxidative killing mechanisms of PMNs are not completely effective under anaerobic conditions. Therefore, antimicrobial agents are used to control these periodontal infections, which include - tetracyclines, ciprofloxacin, metronidazole, and synthetic penicillin, such as amoxicillin. [12],[13] The main reason for choosing these antibiotics is their activity against anaerobic flora, availability in higher concentrations in gingival crevicular fluid, long duration in the tissues, and anticollagenolytic properties. [14],[15] In addition to administration of tetracyclines or metronidazole alone in the treatment of periodontal infections, metronidazole has also been used in combination with amoxicillin because of the drug's synergistic effect. [16],[17]

The aim of this study was to evaluate the effects of a combination of amoxicillin plus metronidazole and systemic tetracycline derivative doxycycline alone in the nonsurgical treatment of localized aggressive periodontitis (LAP) and compare their effects on clinical and microbiological parameters during 90 days follow-up.


  Materials and Methods Top


Twenty subjects, patients of the Department of Periodontics, Mamata Dental College and Hospital, Khammam, were recruited for the study. Each patient was given a detailed verbal description of the study. The research protocol was approved by the local ethical committee and the patients signed a consent form prior to commencement of the study. The subjects were diagnosed with LAP (according to 1999 international classification) [18] as assessed by their prestudy records, which included detailed medical and dental history, assessment of periodontal status, study models, radiographs, and photographs.

Inclusion criteria were - age between 16 and 30 when first diagnosed with LAP, systemically healthy patients, absence of any medication for the last 6 months, and no periodontal therapy for the previous 12 months. The criteria for exclusion were - pregnant or lactating women, presence of systemic diseases or drug allergies, patients on long-term anti-inflammatory therapy, patients having partially erupted or impacted teeth and those not willing to give consent for the study.

Study design

Orthopantomogram (OPG) or full-mouth IOPAs were taken for all the 20 subjects. The subjects were scheduled for collection of baseline samples of subgingival plaque and for recordings of baseline full-mouth clinical parameters, that is, plaque index (PI), gingival index (GI), probing pocket depth (PPD), and clinical attachment loss (CAL).

The subjects were divided into two equal groups (Group I and Group II) based on antibiotic regimen. Patients assigned to Group I (n = 10) were given combined antibiotic therapy with 500 mg amoxicillin (MOKKEM 500, Alkem Laboratories, Mumbai) plus 400 mg metronidazole (METROGYL 400, JB Chemicals and Pharmaceuticals Pvt. Ltd., Ankleshwar) three times a day for 10 days. [19] Patients assigned to Group II (n = 10) were given 100 mg doxycycline (DOXT® -100, Dr. Reddy's Laboratories Ltd., Yanam) for 10 days. The patients were prescribed two tablets on the first day and one tablet for the following 9 days. [19]

The subjects were recalled at day 10. Microbiologic sampling followed by the measurement of clinical parameters was repeated. During this visit, subjects were also given same-day full-mouth scaling and root planing under LA. Subjects were then recalled at days 30 and 90, for microbiologic sampling followed by the measurement of clinical parameters.

Clinical recordings

The following clinical parameters were recorded on four surfaces for all the fully-erupted teeth (buccal, lingual, mesial and distal) - Plaque Index (Silness and Loe, 1964), [20] Gingival Index (Loe and Silness, 1963), [21] Probing Pocket Depth (PPD) and Clinical Attachment Loss (CAL). The probing pocket depth was measured from the crest of the gingival margin to the base of the pocket using a graduated manual probe (UNC-15 mm probe; Hu-Friedy). CAL was recorded using a graduated manual probe (UNC-15 mm probe; Hu-Friedy). Any loss of attachment was calculated from two measurements as follows: CAL = PPD - distance from free gingival margin to CEJ. When the crest of the gingiva was on the root surface, the score was recorded as negative. When the crest of the gingiva was on the enamel, the score was recorded as positive.

Microbiologic sampling

Subgingival plaque samples were taken from the deepest pockets of mesial sites, either right or left, of maxillary first molar teeth from all the subjects (one site per subject). Prior to collection of the subgingival plaque samples, the supragingival areas of the teeth were cleaned with sterile sponges to avoid contaminating the subgingival specimens with supragingival organisms. The selected site was isolated using sterile cotton rolls to avoid salivary contamination. A sterile Gracey curette (No. 11/12 or No. 13/14) was inserted gently into the selected site up to the apical pocket limit and then drawn coronally with sufficient force to collect the most apically located subgingival plaque but not to plane the root [Figure 1]. Care was taken not to contaminate the plaque sample with blood that resulted due to bleeding while manipulating the instrument in the pocket.
Figure 1: Obtaining sample with a Gracey curette

Click here to view


Vials containing transfer media (thioglycollate broth with hemin and Vitamin K 1 ) were taken and the curette tip was vigorously agitated so as to dispense the entire plaque sample into the vial [Figure 2]. The vials were then closed tight and labeled according to the code number allotted to the particular patient. Within 72 h of sample collection, the vials were sent to the laboratory (Department of Microbiology, Maratha Mandal's NGH Institute of Dental Sciences and Research Centre, Belgaum, Karnataka) for culture. All samples were cultured for the three microorganisms - Porphyromonas gingivalis (Pg), Aggregetibacter actinomycetemcomitans (Aa) and Tanerella forsythia (Tf).  The following culture media were used - Brewer's Anaerobic Agar [Figure 3] and Blood Agar (Brain Heart Infusion Agar + Sheep Blood) [Figure 4] for Pg and Aa, and Bacteroides Bile Esculin (BBE) Agar [Figure 5] for Tf. Identification of the three microorganisms was done according to standard protocol using key biochemical reactions. Following culture and identification, the number of colony forming units per ml (CFU/ml) for each microorganism was recorded [Figure 6].
Figure 2: Transferring sample to transport medium in vial

Click here to view
Figure 3: Brewer's anaerobic agar

Click here to view
Figure 4: Blood agar

Click here to view
Figure 5: Bacteroides bile esculin agar

Click here to view
Figure 6: Cultured microorganisms on the culture plates

Click here to view


Statistical analysis

The mean values of plaque index (PI), gingival index (GI), probing pocket depth (PPD), and clinical attachment level (CAL) were compared using the 'Student Unpaired "t" Test'. Intergroup comparisons were made by 'One-way ANOVA'. P value of <0.05 was considered as statistically 'significant' and P value < 0.001 was considered as statistically 'highly significant'. Significant differences between group means were determined using 'Bonferroni Test'.


  Results Top


[Table 1], [Table 2], [Table 3], [Table 4] show the comparison of mean values and the statistical significance of PI, GI, PPD, and CAL scores, respectively, for both groups at baseline and days 10, 30, and 90. [Table 5] describes the microbiologic parameters.
Table 1: Comparison of PI values between group I and group II

Click here to view
Table 2: Comparison of GI values between group I and group II

Click here to view
Table 3: Comparison of PPD between group I and group II

Click here to view
Table 4: Comparison of CAL between group I and group II

Click here to view
Table 5: Antimicrobial counts (Colony forming units-CFU/ml) obtained at baseline and day 10, day 30 and day 90 for group I and group II (in thousands)

Click here to view



  Discussion Top


The furcation region of roots or the dentinal tubules act as a reservoir for persistent pathogenic bacteria even after periodontal surgical procedures alone. Soft tissue wall of the periodontal pocket also acts similarly. [11],[22],[23] Thus, along with mechanical periodontal therapy, an antibacterial treatment approach will suppress pathogenic bacteria and permit recolonization with healthy microorganisms. [24] Currently, data in the literature suggest that systemically administered antimicrobials can enhance the effects of mechanical treatment in the management of aggressive periodontitis as assessed by clinical parameters. However, because of the relative absence of randomized controlled clinical trials including microbiological data, no definitive guidelines exist regarding the most effective antibiotic regime and time of administration for this group of patients. [25] Therefore, this study was designed in order to evaluate the effects of a combination of amoxicillin plus metronidazole and systemic tetracycline derivative doxycycline alone in the nonsurgical treatment of localized aggressive periodontitis (LAP) and compare their effects on clinical and microbiological parameters during 90 days follow-up.

All patients were given detailed oral hygiene instructions during 90 days of follow-up. Doxycycline and amoxicillin plus metronidazole treated patients demonstrated a pattern of decrease in their PI and GI scores during the entire study period compared to baseline PI and GI values. Furthermore, patients treated with doxycycline showed a statically significant decrease in PI and GI scores compared to the PI and GI scores of amoxicillin plus metronidazole treated patients at days 30 and 90. This decrease in PI and GI scores can be attributed to the improved oral hygiene methods of the patients. This is in accordance with the results of studies by Akincibay et al.[19] (who administered doxycycline or amoxicillin plus metronidazole) and Jenkins et al.[26] (who administered metronidazole). However, studies performed by Christersson et al.[27] failed to report any changes in GI scores. This variation in the results may be due to the differences in the study population in terms of their socioeconomic status, education level, and oral hygiene awareness.

It was seen that amoxicillin plus metronidazole and doxycycline-treated patients demonstrated a pattern of decrease in their PPD and CAL values during the entire study period compared to baseline PPD and CAL values. Furthermore, patients treated with doxycycline showed a statistically significant decrease in PPD and CAL values compared to the PPD and CAL values of amoxicillin plus metronidazole treated patients at days 10, 30, and 90. This decrease in PPD and CAL values in both groups can be attributed to the administration of antibiotics in addition to scaling and root planing. This is in accordance with the results of studies by van Winkelhoff [27] (who applied metronidazole plus amoxicillin with mechanical therapy to patients) and Akincibay et al.[19] (who administered doxycycline or amoxicillin plus metronidazole).

Studies have reported the failures in the treatment of patients of LAP with mechanical treatment alone. Clinical and microbiological studies have concluded that treatment of LAP was not complete without the elimination of Aa, Pg, and Tf, and that the efficacy of mechanical treatment was limited. Thus, use of different antibiotics in combination with SRP has been recommended to successfully eliminate periodontal pathogens such as Aa, Pg, and Tf. [5],[28] Studies concerning the use of a single antibiotic or combined antibiotics in addition to mechanical treatment have reported successful results to eliminate periodontal pathogens from periodontal pockets. [17],[29],[30]

In this study, patients with LAP positive for Aa, Pg, and Tf, were given doxycycline or amoxicillin plus metronidazole combination before SRP. The reason for administering antibiotics before the mechanical therapy was initiated to determine the efficacy of the antibiotics alone without the influence of mechanical therapy on the elimination of periodontal pathogens. Aa, Pg, and Tf were found in all patients sampled at the baseline. After antibiotics were given to all patients, only a partial growth was seen in the cultures of three patients given amoxicillin plus metronidazole at day 10. Aa, Pg, and Tf did not grow on bacterial cultures of the rest of the patients given doxycycline or amoxicillin plus metronidazole.

Kapoor et al. [31] and Prakasam et al. [32] have stressed the importance of the use of systemic antibiotics along with mechanical therapy and stated that adjunctive antibiotic treatment frequently results in a more favorable clinical response than mechanical therapy alone. The clinical findings of this study indicate that patients with LAP given doxycycline demonstrated significant improved clinical parameters compared to those given amoxicillin plus metronidazole during 90 days. Where the microbiologic results were concerned, doxycycline showed successful elimination/suppression of Aa, Pg, and Tf completely in 10 days, whereas amoxicillin plus metronidazole showed complete elimination of Pg and Tf but only 70% reduction of Aa in 10 days. However, at days 30 and 90, both antibiotic regimes showed complete elimination of Aa, Pg, and Tf. Baltacioğlu et al. [33] reported that treatment of aggressive periodontitis with SRP plus systemic antibiotics provided significant clinical benefits over treatment with SRP alone, which reduced the need for periodontal surgery. However, their comparison of amoxicillin plus metronidazole and doxycycline alone did not yield any statistically significant difference and no microbiologic parameters were included in their study.

A limitation of this study was that it did not include the socioeconomic status of the participating subjects. Also, there was no comparison with an 'only SRP' group.


  Conclusion Top


When treating LAP, it is imperative that the dental professional employ several treatment modalities to halt further periodontal attachment loss. These modalities may include oral hygiene instructions/reinforcement and evaluation of the patient's plaque control, supra- and subgingival scaling and root planing to remove the bacterial biofilms, implementation of antimicrobials, and periodontal maintenance. The findings of this study indicate that in patients with LAP, systemic administration of doxycycline with full mouth scaling and root planing resulted in a better improvement of periodontal parameters and elimination/suppression of putative periodontal pathogens such as Aa, Pg, and Tf, compared to systemic administration of a combination of amoxicillin plus metronidazole with scaling and root planing.


  Acknowledgments Top


The authors would like to sincerely thank Dr. Kishore G. Bhat, Professor and Head, Department of Mcirobiology, Maratha Mandal's NGH Institute of Dental Sciences and Research Center, Belgaum, for successfully culturing the anaerobic microorganisms mentioned in the study.

 
  References Top

1.
Christersson LA, Emrich LJ, Dunford RG, Genco RJ. Analysis of data from clinical studies of localized juvenile periodontitis. J Clin Periodontol 1986;13:476-87.  Back to cited text no. 1
    
2.
Genco RJ, Christersson LA, Zambon JJ. Juvenile periodontitis. Int Dent J 1986;36:168-76.  Back to cited text no. 2
    
3.
Clark RA, Page RC, Wilde G. Defective neutrophil chemotaxis in juvenile periodontitis. Infect Immun 1977;18:694-700.  Back to cited text no. 3
    
4.
Liljenberg B, Lindhe J. Juvenile periodontitis. Some microbiological, histopathological and clinical characteristics. J Clin Periodontol 1980;7:48-61.  Back to cited text no. 4
    
5.
Zambon JJ, Reynolds HS, Slots J. Black-pigmented bacteroides spp. in the human oral cavity. Infect Immun 1981;32:198-203.  Back to cited text no. 5
    
6.
Listgarten MA. Structure of the microbial flora associated with periodontal health and disease in man. A light and electron microscopic study. J Periodontol 1976;47:1-18.  Back to cited text no. 6
    
7.
Moore WE, Holdeman LV, Cato EP, Smibert RM, Burmeister JA, Palcanis KG, et al. Comparative bacteriology of juvenile periodontitis. Infect Immun 1985;48:507-19.  Back to cited text no. 7
    
8.
Tözüm TF, Berker E, Akincibay H, Ozer O, Aktaº D, Tezcan I, et al . Tetraploid/diploid mosaicism with generalized aggressive periodontitis. J Periodontol 2005;76:1567-71.  Back to cited text no. 8
    
9.
Cacchillo DA, Walters JD. Effect of ciprofloxacin on killing of actinobacillus actinomycetemcomitans by polymorphonuclear leukocytes. Antimicrob Agents Chemother 2002;46:1980-4.  Back to cited text no. 9
    
10.
Haffajee AD, Socransky SS. Microbial etiological agents of destructive periodontal diseases. Periodontol 2000 1994;5:78-111.  Back to cited text no. 10
    
11.
Christersson LA, Albini B, Zambon JJ, Wikesjö UM, Genco RJ. Tissue localization of Actinobacillus actinomycetemcomitans in human periodontitis. I. Light, immunofluorescence and electron microscopic studies. J Periodontol 1987;58:529-39.  Back to cited text no. 11
    
12.
Haffajee AD, Dzink JL, Socransky SS. Effect of modified Widman flap surgery and systemic tetracycline on the subgingival microbiota of periodontal lesions. J Clin Periodontol 1988;15:255-62.  Back to cited text no. 12
    
13.
Tözüm TF, Yildirim A, Caðlayan F, Dinçel A, Bozkurt A. Serum and gingival crevicular fluid levels of ciprofloxacin in patients with periodontitis. J Am Dent Assoc 2004;135:1728-32.  Back to cited text no. 13
    
14.
Lindhe J, Liljenberg B, Adielson B. Effect of long-term tetracycline therapy on human periodontal disease. J Clin Periodontol 1983;10:590-601.  Back to cited text no. 14
    
15.
Lindhe J, Liljenberg B, Adielson B, Börjesson I. Use of metronidazole as a probe in the study of human periodontal disease. J Clin Periodontol 1983;10:100-12.  Back to cited text no. 15
    
16.
van Winkelhoff AJ, Rodenburg JP, Goené RJ, Abbas F, Winkel EG, de Graaff J. Metronidazole plus amoxicillin in the treatment of Actinobacillus actinomycetemcomitans associated periodontitis. J Clin Periodontol 1989;16:128-31.  Back to cited text no. 16
    
17.
van Winkelhoff AJ, Tijhof CJ, de Graaff J. Microbiological and clinical results of metronidazole plus amoxicillin therapy in Actinobacillus actinomycetemcomitans-associated periodontitis. J Periodontol 1992;63:52-7.  Back to cited text no. 17
    
18.
Armitage GC. Development of a classification system for periodontal diseases and conditions. Ann Periodontol 1999;4:1-6.  Back to cited text no. 18
    
19.
Akincibay H, Orsal OB, Sengün D, Tözüm TF. Systemic administration of doxycycline versus metronidazole plus amoxicillin in the treatment of localized aggressive periodontitis: A clinical and microbiologic study. Quintessence Int 2008;39:e33-9.  Back to cited text no. 19
    
20.
Silness J, Loe H. Periodontal disease in pregnancy. II. Correlation between oral hygiene and periodontal condition. Acta Odontol Scand 1964;22:121-35.  Back to cited text no. 20
    
21.
Loe H, Silness J. Periodontal disease in pregnancy. I. Prevalence and severity. Acta Odontol Scand 1963;21:533-51.  Back to cited text no. 21
    
22.
Lavanchy DL, Bickel M, Baehni PC. The effect of plaque control after scaling and root planing on the subgingival microflora in human periodontitis. J Clin Periodontol 1987;14:295-9.  Back to cited text no. 22
    
23.
Adriaens PA, De Boever JA, Loesche WJ. Bacterial invasion in root cementum and radicular dentin of periodontally diseased teeth in humans. A reservoir of periodontopathic bacteria. J Periodontol 1988;59:222-30.  Back to cited text no. 23
    
24.
van Winkelhoff AJ, Rams TE, Slots J. Systemic antibiotic therapy in periodontics. Periodontol 2000 1996;10:45-78.  Back to cited text no. 24
    
25.
Xajigeorgiou C, Sakellari D, Slini T, Baka A, Konstantinidis A. Clinical and microbiological effects of different antimicrobials on generalized aggressive periodontitis. J Clin Periodontol 2006;33:254-64.  Back to cited text no. 25
    
26.
Jenkins WM, MacFarlane TW, Gilmour WH, Ramsay I, MacKenzie D. Systemic metronidazole in the treatment of periodontitis. J Clin Periodontol 1989;16:443-50.  Back to cited text no. 26
    
27.
Christersson LA, Slots J, Rosling BG, Genco RJ. Microbiological and clinical effects of surgical treatment of localized juvenile periodontitis. J Clin Periodontol 1985;12:465-76.  Back to cited text no. 27
    
28.
Asikainen S. Occurrence of Actinobacillus actinomycetemcomitans and spirochetes in relation to age in localized juvenile periodontitis. J Periodontol 1986;57:537-41.  Back to cited text no. 28
    
29.
van Winkelhoff AJ, van Steenbergen TJ, de Graaff J. The role of black-pigmented bacteroides in human oral infections. J Clin Periodontol 1988;15:145-55.  Back to cited text no. 29
    
30.
Mandell RL, Socransky SS. Microbiologic and clinical effects of surgery plus doxycycline on juvenile periodontitis. J Periodontol 1988;59:373-9.  Back to cited text no. 30
    
31.
Kapoor A, Malhotra R, Grover V, Grover D. Systemic antibiotic therapy in periodontics. Dent Res J (Isfahan) 2012;9:505-15.  Back to cited text no. 31
    
32.
Prakasam A, Elavarasu SS, Natarajan RK. Antibiotics in the management of aggressive periodontitis. J Pharm Bioallied Sci 2012;4 Suppl 2:S252-5.  Back to cited text no. 32
    
33.
Baltacioglu E, Aslan M, Saraç Ö, Saybak A, Yuva P. Analysis of clinical results of systemic antimicrobials combined with nonsurgical periodontal treatment for generalized aggressive periodontitis: A pilot study. J Can Dent Assoc 2011;77:b97.  Back to cited text no. 33
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
Abstract
Introduction
Materials and Me...
Results
Discussion
Conclusion
Acknowledgments
References
Article Figures
Article Tables

 Article Access Statistics
    Viewed2359    
    Printed36    
    Emailed0    
    PDF Downloaded431    
    Comments [Add]    

Recommend this journal