Effectiveness of systemic amoxicillin/metronidazole as an adjunctive therapy to full-mouth scaling and root planing in the treatment of aggressive periodontitis: a systematic review and meta-analysis

The effect of metronidazole plus amoxicillin or metronidazole plus penicillin V on periodontal pathogens in an in vitro biofilm model

A combination of metronidazole (MET) and amoxicillin (AMX) is commonly used as adjunct to mechanical therapy of periodontal disease. The use of broad spectrum antibiotics such as AMX may contribute to development of antibiotic resistance. The aim was to evaluate the in vitro effect of replacing AMX with penicillin V (PV) in combination with MET on a biofilm model. A biofilm model consisting of Aggregatibacter actinomycetemcomitans, Porphyromonas gingivalis, and Fusobacterium nucleatum was developed. The biofilms were exposed to AMX + MET and PV + MET in two different concentrations. Bacterial viability in biofilms following antibiotic exposure was assessed by viable counts and by confocal microscopy. No live colonies of P. gingivalis nor F. nucleatum were retrieved from biofilms exposed to AMX + MET or PV + MET. The amount of A. actinomycetemcomitans was 4-5 logs reduced following antibiotic treatment; no statistical significance was achieved between AMX + MET or PV + MET treated biofilms. Replacement of AMX with PV at the same concentration, in combination with MET, resulted in similar effect on bacterial viability in this in vitro model. The option of using PV + MET instead of AMX + MET deserves further investigation, as this may contribute to reduce the risk of antibiotic resistance development.

Microbial colonization of the periodontal pocket and its significance for periodontal therapy

The aim of this paper was to evaluate strategies for periodontal therapy from the perspective of periodontal disease being a consequence of microbial colonization of the periodontal pocket environment. In classic bacterial infections the diversity of the microbiota decreases as the disease develops. In most cases of periodontitis, however, the diversity of the flora increases. Most incriminating bacteria are thought to harm tissues significantly only if present in high numbers over prolonged periods of time. Clinical trials have repeatedly demonstrated that scaling and root planing, a procedure that aims to remove subgingival bacterial deposits by scraping on the tooth surface within the periodontal pocket, is effective. At present, for the therapy of any form of periodontal disease, there exists no protocol with proven superiority, in terms of efficiency or effectiveness, over scaling and root planing plus systemic amoxicillin and metronidazole. Some exponents advocate rationing these drugs for patients with a specific microbial profile. However, the evidence for any benefit of bacteriology-assisted clinical protocols is unsatisfactory. Treated sites are subject to recolonization with a microbiota similar to that present before therapy. The degree and speed of recolonization depends on the treatment protocol, the distribution patterns of periodontal microorganisms elsewhere in the oral cavity and the quality of the patient's oral hygiene. To limit the use of antibiotics and to avoid accumulation of harmful effects by repeated therapy, further efforts must be made to optimize procedures addressing the microbial colonization and recolonization of the periodontal pocket.

Comparison of adjunctive azithromycin and amoxicillin/metronidazole for patients with chronic periodontitis: preliminary randomized control trial

BACKGROUND

There are insufficient guidelines for the use of adjunctive systemic antibiotics for patients with periodontal disease. The aim of this study was to compare clinical outcomes for patients with moderate-advanced chronic periodontitis treated with: scaling and root planing (SRP), SRP with amoxicillin and metronidazole (A+M), SRP with Azithromycin (Az).

METHODS

Thirty-seven non-smokers with generalized moderate to advanced chronic periodontitis were divided into three treatment groups: SRP, A+M and Az. Patients received the medications after the last SRP session and were reviewed three months later. Changes in clinical parameters were compared between the groups. Separate analyses were executed for: 'all sites', 'molar sites', 'sites with different PPD severities' and 'number of sites with shallow, moderate and deep PPD'.

RESULTS

The three groups exhibited improvements in most clinical parameters. At three months, A+M showed a higher reduction in PPD compared to Az in the 'all sites analysis'. Molars exhibited better reduction in BOP and PPD with A+M than SRP. Pocket depth of the 4-6 mm category reduced more in the A+M than SRP. A+M experienced a higher increase in the number of sites with PPD 1-3 mm than Az.

CONCLUSIONS

Adjunctive systemic antibiotics in the initial phase of treatment may result in improved clinical outcomes.

Systemic antimicrobials adjuvant to periodontal therapy in diabetic subjects: a meta-analysis

BACKGROUND

Adjuvant antibiotics have been suggested to improve periodontal therapy in diabetic subjects.

AIM

The aim of this study was to systematically review randomized clinical trials assessing systemic antimicrobial use adjuvant to scaling and root planing (SRP) versus SRP alone in diabetic subjects.

MATERIAL AND METHODS

The PubMed, Cochrane Central Register of Controlled Trials, EMBASE, TRIP, Web of Science and LILACS databases and the grey literature were searched through May 2015. Of 2534 potentially eligible studies, 13 were included in the systematic review. Weighted mean differences (WMDs) in probing depth (PD) reduction and clinical attachment level (CAL) gain (primary outcomes), and plaque index (PI) and bleeding on probing (BOP) reductions, were estimated using a random effect model.

RESULTS

The WMD in PD reduction [-0.15 mm, n = 11, p = 0.001, 95% confidence interval (CI) -0.24, -0.06] favoured antibiotic use. WMDs in CAL gain, PI and BOP reductions (-0.14 mm, n = 9, p = 0.11, 95% CI -0.32, 0.03; 4.01%, n = 7, p = 0.05, 95% CI -0.04, 8.07; and -1.91%, n = 7, p = 0.39, 95% CI -6.32, 2.51 respectively) did not favour adjunctive antibiotic use.

CONCLUSION

Adjunctive therapy may improve the efficacy of SRP in reducing PD in diabetic subjects.

Effects on HbA1c in diabetic patients of adjunctive use of systemic antibiotics in nonsurgical periodontal treatment: A systematic review

OBJECTIVE

To assess the effects of adjunctive use of systemic antibiotics in nonsurgical periodontal treatment compared to nonsurgical periodontal treatment alone, on mean glycated hemoglobin (HbA1c) reductions in patients with diabetes.

DATA

Two independent reviewers screened six electronic databases, registers of clinical trials, meeting abstracts and four major dental journals for controlled clinical trials with at least 3-month follow-up.

SOURCES

After duplicates removal, electronic and hand searches yielded 2136 records; 32 full-text articles were independently read by two reviewers. To evaluate the additional effect of antibiotic usage, pooled weighted mean differences and 95% confidence intervals were calculated using fixed and random effects models.

STUDY SELECTION

Twelve studies met the inclusion criteria, nine of which provided data that allowed their inclusion in meta-analyses. The meta-analyses showed no significant effect favouring scaling and root planing (SRP) plus antibiotic for reductions in mean HbA1c (-0.11% [-0.35, 0.13]; 6 studies), and an estimated prediction interval varying from -0.45 to 0.23. There was also no significant effect favouring the adjunctive usage of sub-antimicrobial doxycycline in HbA1c mean reduction (-0.19% [-1.04, 0.67]; 2 studies).

CONCLUSION

Adjunctive use of systemic antibiotic provides no statistically significant benefit in terms of HbA1c improvement in periodontal treatment of patients with diabetes.

CLINICAL SIGNIFICANCE

Adjunctive use of systemic antibiotics associated with nonsurgical periodontal treatment provides no additional benefit in terms of HbA1c of diabetic patients. Clinicians should weigh the trade-off between risks and benefits provided by the use of systemic antibiotics before prescribing them for periodontal disease treatment.

Antibiotics/antimicrobials: systemic and local administration in the therapy of mild to moderately advanced periodontitis

This review gives an update of the current scientific evidence on the efficacy of the adjunctive use of systemic and local antibiotics/antimicrobials in the treatment of periodontitis. In particular, it addresses whether their use can improve the results of nonsurgical mechanical therapy in mild-to-moderate forms of the disease. Large numbers of randomized clinical trials and systematic reviews with meta-analyses have clearly established that adjunctive systemic antibiotics, combined with mechanical debridement, offer clinical improvements additional to those obtained with scaling and root planing alone. These effects are more pronounced in aggressive periodontitis and in initially deep pockets, whereas more limited additional improvements, of 0.3 mm for additional pocket reduction and 0.2 mm for additional clinical attachment gain, have been documented for moderately deep sites (4-6 mm) in patients with chronic periodontitis. The marginal clinical benefit in patients with moderate disease has to be balanced against possible side effects. Notably, it has to be realized that an increasing number of warnings have been articulated against the unrestricted use of antibiotics in treating periodontal diseases because of the emerging global public health issue of bacterial resistance. The effects of the adjunctive local administration of antimicrobials have also been very well documented in several systematic reviews. Overall, in persistent or recurrent localized deep sites, the application of antimicrobials by sustained-delivery devices may offer a benefit of an additional 0.4 mm in pocket depth reduction and 0.3 mm in clinical attachment level gain. In conclusion, the slight additional benefits of adjunctive antimicrobials, which were shown for moderate forms of periodontitis, have to be balanced against their side effects and therefore their prescription should be limited as much as possible.

Systemic antibiotics in the treatment of periodontitis

Despite the fact that several clinical studies have shown additional benefits when certain systemic antibiotics are used as adjuncts to periodontal treatment, clear guidelines for the use of these agents in the clinical practice are not yet available. Basic questions concerning the use of systemic antibiotics to treat periodontitis remain unanswered, such as: which drug(s) should be used; which patients would most benefit from treatment; which are the most effective protocols (i.e. doses and durations); and in which phase of the mechanical therapy should the drug(s) be administered? Although not all of those questions have been directly addressed by controlled randomized clinical trials, recent concepts related to the ecology of periodontal diseases, as well as the major advances in laboratory and clinical research methods that have occurred in the past decade, have significantly broadened our knowledge in this field. This article endeavored to provide a 'state of the art' overview on the use of systemic antibiotics in the treatment of periodontitis, based on the most recent literature on the topic as well as on a compilation of data from studies conducted at the Center of Clinical Trials at Guarulhos University (São Paulo, Brazil) from 2002 to 2012.

Long-term clinical response to treatment and maintenance of localized aggressive periodontitis: a cohort study

AIM

To evaluate long-term clinical response to periodontal therapy and maintenance in localized aggressive periodontitis (LAP).

MATERIALS AND METHODS

One hundred forty-one African Americans diagnosed with LAP, aged 5-25 years, were enrolled. Patients underwent periodontal mechanical debridement plus 1 week of amoxicillin/metronidazole. Mechanical therapy was repeated as needed and clinical parameters were recorded at baseline, 3, 6, 12, 18 and 24 months, and two additional annual follow-up visits after treatment. Radiographs from primary dentition of patients with LAP in permanent dentition, and additional healthy siblings (HS) were analysed retrospectively.

RESULTS

Periodontal therapy significantly improved probing depth and clinical attachment level up to 4 years (mean reductions: 2.18 ± 1.03 and 2.80 ± 1.43 mm, respectively). Percentage of affected sites was reduced at all time points and maintained up to 4 years. Non-compliance with antibiotics/appointments negatively affected the treatment response. Ninety per cent of LAP patients in permanent dentition and 32% of HS presented radiographic bone loss in primary dentition.

CONCLUSIONS

Mechanical debridement with 1 week of systemic antibiotics along with proper periodontal maintenance was effective in the treatment and successful maintenance of LAP for up to 4 years. LAP in permanent dentition may be preceded in the primary dentition. Clinicaltrials.gov #NCT01330719.

Efficacy of Local Antimicrobials in the Non-Surgical Treatment of Patients With Periodontitis and Diabetes: A Systematic Review

BACKGROUND

Patients with diabetes present a worse response to periodontal treatment. Local antimicrobials as an adjunct to scaling and root planing (SRP) provide additional benefits in the treatment of periodontitis in healthy patients. This review aims to evaluate the effects of local antimicrobials as an adjunct to SRP, compared with SRP alone, on periodontal clinical parameters of patients with chronic periodontitis (CP) and diabetes mellitus (DM).

METHODS

Only randomized controlled trials with: 1) at least 6 months of follow-up; 2) SRP, in combination with local antimicrobials; and 3) patients with periodontitis and DM were considered eligible. MEDLINE, EMBASE, and LILACS databases were searched for articles published up to January 2016. Random-effects meta-analyses were conducted for clinical attachment level (CAL), probing depth (PD), bleeding on probing, and gingival index change after treatment.

RESULTS

Of 153 papers potentially relevant to this review, six were included. The majority of trials showed a significant PD reduction and CAL gain associated with use of local antimicrobials in patients with type 1 and type 2 DM. Only studies that included well-controlled patients and applied antimicrobials at the deepest sites or sites with baseline PD ≥5 mm presented significant PD reduction and CAL gain.

CONCLUSION

In patients with DM and CP, use of local antimicrobials as an adjunct to SRP may result in additional benefits compared with SRP alone in PD reduction and CAL gain, especially in well-controlled individuals and deep sites.

Local disinfection with sodium hypochlorite as adjunct to basic periodontal therapy: a randomized controlled trial

AIM

To investigate the clinical and microbiological effects of local disinfection with 0.5% sodium hypochlorite (NaOCl) with or without systemic antimicrobials (amoxicillin and metronidazole, AM) during basic periodontal therapy (BPT).

MATERIAL AND METHODS

In a randomized clinical trial (four groups), 110 chronic periodontitis patients received BPT plus local irrigation with saline (BPT + S), local disinfection with NaOCl (BPT + DIS), BPT + DIS + AM or BPT + S + AM. The outcome was analysed at baseline, 3, 6 and 12 months.

RESULTS

There was no difference in clinical attachment level gain at 12 months between the four groups. BPT + DIS showed no additional improvement compared to BPT + S; BPT + DIS + AM showed fewer sites with probing pocket depth (PPD) ≥7 mm versus BPT + S only up to 6 months (p = 0.037). In factorial analyses, additional clinical reduction for PPD (p = 0.023) and number of sites with PPD ≥5 (p = 0.007), ≥6 (p = 0.002) and ≥7 mm (p < 0.001) were found when AM was added to BPT, but not when DIS was applied. In all groups, a comparable decrease in targeted bacteria was found. AM caused adverse events in 22% of the patients.

CONCLUSION

Local disinfection with NaOCl, also in combination with AM, showed, after 1-year follow-up, no additional clinical and microbiological effects compared to BPT alone.

Adjunctive use of essential oils following scaling and root planing -a randomized clinical trial

BACKGROUND

Hitherto no study has been published on the effect of the adjunctive administration of essential oils following scaling and root planing (SRP). This study describes the effect of a mouthrinse consisting of essential oils (Cymbopogon flexuosus, Thymus zygis and Rosmarinus officinalis) following SRP by clinical and microbiological variables in patients with generalized moderate chronic periodontitis.

METHODS

Forty-six patients (aged 40-65 years) with moderate chronic periodontitis were randomized in a double-blind study and rinsed their oral cavity following SRP with an essential oil mouthrinse (n  =  23) or placebo (n  =  23) for 14 days. Probing depth (PD), attachment level (AL), bleeding on probing (BOP) and modified sulcus bleeding index (SBI) were recorded at baseline and after 3 and 6 months. Subgingival plaque was taken for assessment of major bacteria associated with periodontitis.

RESULTS

AL, PD, BOP and SBI were significantly improved in both groups after three (p   <   0.001) and 6 months (p   ≤   0.015). AL improved significantly better in the test than in the control group after 3 and 6 months (p < 0.001), so did PD after three months in the tendency (p  =  0.1). BOP improved better in the test group after 3 months (p  =  0.065). Numbers of Treponema denticola (p  =  0.044) and Fusobacterium nucleatum (p  =  0.029) decreased more in the test than in the control group after 3 months, those of Tannerella forsythia after 6 months (p  =  0.039). Prevotella micra (p  <  0.001, p  =  0.035) and Campylobacter rectus (p  =  0.002 , p  =  0.012) decreased significantly in both groups after 3 months.

CONCLUSIONS

The adjunctive use of a mouthrinse containing essential oils following SRP has a positive effect on clinical variables and on bacterial levels in the subgingival biofilm.

TRIAL REGISTRATION

332-12-24092012, DRKS 00009387, German Clinical Trials Register, Freiburg i. Br., 16.09.2015.

Clinical efficacy of probiotics as an adjunctive therapy to non-surgical periodontal treatment of chronic periodontitis: a systematic review and meta-analysis

FOCUSED QUESTION

What is the clinical influence of probiotics as an adjunctive therapy of scaling and root planing (SRP) when compared with SRP alone or in combination with placebo in the treatment of chronic periodontitis (CP).

METHODS

Electronic databases were searched up to July 2015. Randomized controlled trials (RCTs) comparing SRP + probiotic versusSRP were included. PPD reduction and CAL gain were selected as primary outcome variables.

RESULTS

Independent screening resulted in four eligible publications for the systematic review and three were included in the meta-analysis. Meta-analysis showed a statistically significant CAL gain (-0.42 mm, p = 0.002) and bleeding on probing (BOP) reduction (-14.66, p = 0.003) for SRP + probiotic treatment versusSRP at short-term. Only a tendency (p = 0.06) has been observed in terms of overall PPD reduction, whereas results were significant when stratified for moderate (-0.18, p = 0.001) and deep pockets (-0.67, p < 0.001).

CONCLUSION

Within the limitations of this study, the findings of this meta-analysis seem to support the adjunctive use of L. reuteri to SRP in CP treatment at short-term, especially in deep pockets. Heterogeneity and limited available data may reduce the impact of these conclusions. Future long-term RCTs evaluating the clinical efficacy of adjunctive probiotics to SRP are needed.

Amoxicillin Plus Metronidazole Therapy for Patients with Periodontitis and Type 2 Diabetes

The aim of this study was to assess the changes occurring in subgingival biofilm composition and in the periodontal clinical parameters of subjects with periodontitis and type 2 diabetes mellitus (DM) treated by means of scaling and root planing (SRP) only or combined with systemic metronidazole (MTZ) and amoxicillin (AMX). Fifty-eight subjects were randomly assigned to receive SRP only ( n = 29) or with MTZ (400 mg/thrice a day [TID]) and AMX (500 mg/TID) ( n = 29) for 14 d. Six subgingival plaque samples/subject were analyzed by checkerboard DNA–DNA hybridization for 40 bacterial species at baseline and 3 mo, 1 y, and 2 y posttherapy. At 2 y posttherapy, the antibiotic-treated group harbored lower mean proportions (5.5%) of red complex pathogens than the control group (12.1%) ( P < 0.05). The proportions of the Actinomyces species remained stable in the antibiotic group but showed a statistically significant reduction in the control group from 1 to 2 y in subjects achieving a low risk clinical profile for future disease progression (i.e., ≤4 sites with probing depth [PD] ≥5 mm). The test group also had a lower mean number of sites with PD ≥5 mm (3.5 ± 3.4) and a higher percentage of subjects reaching the low risk clinical profile (76%) than the control group (14.7 ± 13.1 and 22%, respectively) ( P < 0.05) at 2 y posttreatment. MTZ + AMX intake was the only significant predictor of subjects achieving the low risk at 2 y (odds ratio, 20.9; P = 0.0000). In conclusion, the results of this study showed that the adjunctive use of MTZ + AMX improves the microbiological and clinical outcomes of SRP in the treatment of subjects with generalized chronic periodontitis and type 2 DM up to 2 y ( ClinicalTrials.gov NCT02135952).

The concomitant administration of systemic amoxicillin and metronidazole compared to scaling and root planing alone in treating periodontitis: =a systematic review=

Background

The treatment of periodontitis begins with a non-surgical phase that includes scaling and root planing(SRP) and on occasion the use of systemic antibiotics. The goal was to systematically evaluate in systemic healthy adults the effect of the concomitant administration of amoxicillin (amx) and metronidazole (met) adjunctive to SRP compared to SRP alone.

Methods

The PubMed-MEDLINE, Cochrane-CENTRAL and EMBASE databases were searched up to November 2014 to identify appropriate studies. Probing Pocket Depth (PD), Clinical Attachment Level (CAL), Bleeding on Pocket Probing(BOP) and Plaque Indices(PI) were selected as outcome variables. Based on the extracted data a meta-analysis was conducted.

Results

A total of 526 unique articles were found, 20 studies met the eligibility criteria. A meta-analysis showed that SRP + amx + met provided significantly better effects overall and more pronounced PD reduction in periodontal pockets initially measuring ≥6 mm (DiffM:-0.86 mm, p < 0.00001) and gain in CAL(DiffM:+0.75 mm, p = 0.0001). The meta-analysis for the secondary inflammatory parameter BOP showed that SRP + amx + met provided full mouth significantly greater reduction in BOP than SRP alone (DiffM:-6.98 %, p = 0.0001).

Conclusion

Adjunctive systemic amoxicillin and metronidazole medication to SRP significantly improved the clinical outcomes with respect to mean PD, CAL and BOP compared to SRP alone. There is moderate to strong evidence in support of the recommendation that adjunctive amx + met therapy to SRP significantly improves the clinical outcomes, with respect to mean PD and CAL compared to SRP alone especially in initially deep (≥6 mm) pockets. No major side effects associated with the intake of amx + met were reported. This treatment regimen is an efficacious, minimally invasive, practical and inexpensive approach for periodontitis therapy. The key components are mechanical tooth and pocket debridement, supportive treatment of the disease with systemic antibiotics and attention to proper self-care.

Electronic supplementary material

The online version of this article (doi:10.1186/s12903-015-0123-6) contains supplementary material, which is available to authorized users.

Microbial profiles at baseline and not the use of antibiotics determine the clinical outcome of the treatment of chronic periodontitis

Antibiotics are often used in the treatment of chronic periodontitis, which is a major cause of tooth loss. However, evidence in favour of a microbial indication for the prescription of antibiotics is lacking, which may increase the risk of the possible indiscriminate use of antibiotics, and consequent, microbial resistance. Here, using an open-ended technique, we report the changes in the subgingival microbiome up to one year post-treatment of patients treated with basic periodontal therapy with or without antibiotics. Antibiotics resulted in a greater influence on the microbiome 3 months after therapy, but this difference disappeared at 6 months. Greater microbial diversity, specific taxa and certain microbial co-occurrences at baseline and not the use of antibiotics predicted better clinical treatment outcomes. Our results demonstrate the predictive value of specific subgingival bacterial profiles for the decision to prescribe antibiotics in the treatment of periodontitis, but they also indicate the need for alternative therapies based on ecological approaches.

Systemic Antibiotics in Periodontal Treatment of Diabetic Patients: A Systematic Review

Aim

To evaluate the effects of systemic antibiotics in combination with scaling and root planing (SRP) on periodontal parameters, tooth loss and oral health-related quality of life in diabetes patients.

Materials and Methods

Two independent reviewers screened for controlled clinical trials with at least 6-month follow-up in six electronic databases, registers of clinical trials, meeting abstracts and four major dental journals. After duplicates removal, electronic and hand searches yielded 1,878 records; 18 full-text articles were independently read by two reviewers. To evaluate the additional effect of antibiotic usage, pooled weighted mean differences and 95% confidence intervals were calculated using a fixed effects model.

Results

Five studies met the inclusion criteria, four of which were included in meta-analyses. The meta-analyses showed a significant effect favouring SRP plus antibiotic for reductions in mean probing depth (PD) (-0.22 mm [-0.34, -0.11]) and mean percentage of bleeding on probing (BoP) (4% [-7, -1]). There was no significant effect for clinical attachment level gain and plaque index reduction. No study reported on tooth loss and oral health-related quality of life.

Conclusion

Adjunctive systemic antibiotic use in diabetic patients provides a small additional benefit in terms of reductions in mean PD and mean percentage of BoP.

Registration

PROSPERO: CRD42013006389.

Nonsurgical therapy of chronic periodontitis with adjunctive systemic azithromycin or amoxicillin/metronidazole

OBJECTIVES

The objective of the present study is to compare the effect of systemic adjunctive use of azithromycin with amoxicillin/metronidazole to scaling and root planing (SRP) in a clinical study.

MATERIALS AND METHODS

Data from 60 individuals with chronic periodontitis were evaluated after full-mouth SRP. Antibiotics were given from the first day of SRP, in the test group (n = 29), azithromycin for 3 days and, in the control group (n = 31), amoxicillin/metronidazole for7 days. Probing depth (PD), attachment level (AL), and bleeding on probing (BOP) were recorded at baseline and after 3 and 12 months. Gingival crevicular fluid was analyzed for matrix metalloprotease (MMP)-8 and interleukin (IL)-1beta levels. Subgingival plaque was taken for assessment of the major bacteria associated with periodontitis.

RESULTS

In both groups, PD, AL, and BOP were significantly reduced (p < 0.001). A few significant differences between the groups were found; AL and BOP were significantly better in the test than in the control group at the end of the study (p = 0.020 and 0.009). Periodontopathogens were reduced most in the test group.

CONCLUSIONS

A noninferiority of the treatment with azithromycin in comparison with amoxicillin/metronidazole can be stated. The administration of azithromycin could be an alternative to the use of amoxicillin/metronidazole adjunctive to SRP in patients with moderate or severe chronic periodontitis; however, a randomized placebo-controlled multicenter study is needed.

CLINICAL RELEVANCE

Application of azithromycin as a single antibiotic for 3 days might be considered as an additional adjunctive antibiotic to SRP in selected patients.

The effect of systemic antibiotics administered during the active phase of non-surgical periodontal therapy or after the healing phase: a systematic review

Objective

The aim of this systematic review was to compare the clinical effectiveness of systemic antibiotics administered in the active stage of periodontal treatment or after the healing phase.

Material and Methods

An electronic search was performed in the databases EMBASE, MEDLINE and Cochrane Central Register of Controlled Trials (CENTRAL), in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) statement. A manual search of the reference list of selected studies and of review articles was also performed up to November 2013. Randomized Clinical Trials (RCT) that evaluated the systemic administration of antibiotics as adjuvants to scaling and root planning (SRP) at different phases of periodontal treatment were included. Systematic reviews and studies that evaluated subjects with systemic diseases and those that used subantimicrobial doses of antibiotics were excluded.

Results

The initial search identified 1,039 articles, of which seven were selected, and only one met the inclusion criteria. This study showed that subjects taking metronidazole and amoxicillin at the initial phase of treatment exhibited statistically significantly greater reduction in pocket depth and gain in clinical attachment level in initially deep sites (PD≥7 mm) than subjects taking antibiotics after healing (p<0.05). This comparison was conducted 2 months after antibiotic intake, at the healing phase.

Conclusion

To date, only one short-term RCT has directly compared different moments of systemic antibiotics administration, as adjuncts to SRP, in the treatment of periodontitis. Although the results of this study suggested some benefits for antibiotics intake during the active phase of therapy, these findings need to be confirmed by larger placebo-controlled randomized clinical trials with longer follow-up periods.

Should Antibiotics Be Prescribed to Treat Chronic Periodontitis?

Although scaling and root planing is a cost-effective approach for initial treatment of chronic periodontitis, it fails to eliminate subgingival pathogens and halt progressive attachment loss in some patients. Adjunctive use of systemic antibiotics immediately after completion of scaling and root planing can enhance the degree of clinical attachment gain and probing depth reduction provided by nonsurgical periodontal treatment. This article discusses the rationale for prescribing adjunctive antibiotics, reviews the evidence for their effectiveness, and outlines practical issues that should be considered before prescribing antibiotics to treat chronic periodontitis.

Non-surgical periodontal therapy supplemented with systemically administered azithromycin: a systematic review of RCTs

BACKGROUND

Azithromycin may be an alternative adjunctive systemic antibiotic in non-surgical periodontal therapy.

OBJECTIVE

This study aims to identify randomized controlled trials evaluating non-surgical periodontal treatment of chronic and/or aggressive periodontitis supplemented with systemically administered azithromycin.

MATERIALS AND METHODS

A systematic literature search was performed for publications published by 31 March 2014 using electronic databases and hand search. Randomized controlled trials published in English or German language, with a follow-up ≥6 months were included. From 231 titles identified, nine publications were eligible for inclusion.

RESULTS

Among the studies included, showing some risk of bias, seven reported on patients with chronic periodontitis and two with aggressive periodontitis. Minor adverse events were described in five studies. A synthesis of results using a vote counting method was applied. Significant (p < 0.05) beneficial effects of azithromycin were shown in six studies for probing depth changes and in five studies for clinical attachment level changes.

CONCLUSION

In contrast to aggressive periodontitis patients, data from this analysis indicate a potential benefit of systemic azithromycin as adjunctive to non-surgical periodontal therapy in chronic periodontitis patients.

CLINICAL RELEVANCE

When contraindications for the standard antibiotics are present, azithromycin (AZM) may be considered as alternative systemically administered antibiotic drug in selected cases of chronic periodontitis.

An estimate of pocket closure and avoided needs of surgery after scaling and root planing with systemic antibiotics: a systematic review

BACKGROUND

Relevant benefits of adjunctive medication of antibiotica after conventional root surface debridement in terms of enhanced pocket depth (PD) reduction have been shown. However, means and standard deviations of enhanced reductions are difficult to translate into clinical relevant treatment outcomes such as pocket resolution or avoidance of additional surgical interventions. Accordingly, the aim of this systematic review was to calculate odds ratios for relevant cut-off values of PD after mechanical periodontal treatment with and without antibiotics, specifically the combination of amoxicilline and metronidazol, from published studies. As clinical relevant cut-off values "pocket closure" for PD ≤ 3mm and "avoidance of surgical intervention" for PD ≤ 5 mm were determined.

METHODS

The databases PubMed, Embase and Central were searched for randomized clinical studies assessing the beneficial effect of the combination of amoxicillin and metronidazole after non-surgical mechanical debridement. Titles, abstracts and finally full texts were scrutinized for possible inclusion by two independent investigators. Quality and heterogeneity of the studies were assessed and the study designs were examined. From published means and standard deviations for PD after therapy, odds ratios for the clinically relevant cut-off values were calculated using a specific statistical approach.

RESULTS

Meta-analyses were performed for the time points 3 and 6 month after mechanical therapy. Generally, a pronounced chance for pocket closure from 3 to 6 months of healing was shown. The administration of antibiotics resulted in a 3.55 and 4.43 fold higher probability of pocket closure after 3 and 6 months as compared to mechanical therapy alone. However, as the estimated risk for residual pockets > 5 mm was 0 for both groups, no odds ratio could be calculated for persistent needs for surgery. Generally, studies showed a moderate to high quality and large heterogeneity regarding treatment protocol, dose of antibiotic medication and maintenance.

CONCLUSION

With the performed statistical approach, a clear benefit in terms of an enhanced chance for pocket closure by co-administration of the combination of amoxicillin and metronidazole as an adjunct to non-surgical mechanical periodontal therapy has been shown. However, data calculation failed to show a benefit regarding the possible avoidance of surgical interventions.

Differential benefits of amoxicillin-metronidazole in different phases of periodontal therapy in a randomized controlled crossover clinical trial

BACKGROUND

The specific advantage of administering systemic antibiotics during initial, non-surgical therapy or in the context of periodontal surgery is unclear. This study assesses the differential outcomes of periodontal therapy supplemented with amoxicillin-metronidazole during either the non-surgical or the surgical treatment phase.

METHODS

This is a single-center, randomized placebo-controlled crossover clinical trial with a 1-year follow-up. Eighty participants with Aggregatibacter actinomycetemcomitans-associated moderate to advanced periodontitis were randomized into two treatment groups: group A, antibiotics (500 mg metronidazole plus 375 mg amoxicillin three times per day for 7 days) during the first, non-surgical phase of periodontal therapy (T1) and placebo during the second, surgical phase (T2); and group B, placebo during T1 and antibiotics during T2. The number of sites with probing depth (PD) >4 mm and bleeding on probing (BOP) per patient was the primary outcome.

RESULTS

A total of 11,212 sites were clinically monitored on 1,870 teeth. T1 with antibiotics decreased the number of sites with PD >4 mm and BOP per patient significantly more than without (group A: from 34.5 to 5.7, 84%; group B: from 28.7 to 8.7, 70%; P <0.01). Twenty patients treated with antibiotics, but only eight treated with placebo, achieved a 10-fold reduction of diseased sites (P = 0.007). Consequently, fewer patients of group A needed additional therapy, the mean number of surgical interventions was lower, and treatment time in T2 was shorter. Six months after T2, the mean number of residual pockets (group A: 2.8 ± 5.2; group B: 2.2 ± 5.0) was not significantly different and was sustained over 12 months in both groups.

CONCLUSION

Giving the antibiotics during T1 or T2 yielded similar long-term outcomes, but antibiotics in T1 resolved the disease quicker and thus reduced the need for additional surgical intervention.

Non-surgical periodontal therapy: An update on current evidence

Periodontal disease is an inflammatory condition that involves a complex interaction between pathogenic bacteria, environmental and acquired factors and host related factors. Till recently periodontal treatment was directed primarily towards reduction of bacterial load by subgingival debridement of root surfaces and modification of environmental risk factors. The current paradigm of periodontal disease stresses greater role of host-mediated inflammatory response in tissue destruction characteristic of periodontal disease. Various therapeutic modalities have been developed adjuvant to mechanical periodontal therapy. The use of laser and photodynamic therapy show great promise but their effectiveness has still not been conclusively proven. Chemotherapeutic agents, either systemic and local antimicrobials or host modulating drugs, played pivotal role in better and more predictable management of periodontal disease. The present review focuses on the best available evidence, for the current management of the chronic periodontal patients, gathered from systematic reviews and meta-analysis of mechanical non surgical periodontal therapy (NSPT) (subgingival debridement, laser therapy and photodynamic therapy) and the adjunctive chemotherapeutic approaches such as systematic and local antibiotics and antiseptics, subgingival pocket irrigation and host modulation therapies. The review also attempts to briefly introduce future developments in some of these modalities. At the end, the review summarizes the analysis of the current evidence that suggests that thorough subgingival debridement remains the mainstay of NSPT and that adjunct use of chemotherapeutic agents may offer better management of clinical parameters in periodontitis patients.

Metronidazole alone or with amoxicillin as adjuncts to non-surgical treatment of chronic periodontitis: a secondary analysis of microbiological results from a randomized clinical trial

AIM

To evaluate the changes occurring in the subgingival microbial profile of subjects with generalized chronic periodontitis (ChP) treated by scaling and root planing (SRP) alone or with metronidazole (MTZ) or MTZ + amoxicillin(AMX). A secondary aim was to examine a possible added effect of chlorhexidine(CHX) to these therapies.

METHODS

One hundred and eighteen subjects were randomly assigned to receive SRP-only or with MTZ [400 mg/thrice a day (TID)] or MTZ + AMX (500 mg/TID) for 14 days. Half of the subjects in each group rinsed with 0.12% CHX twice a day (BID) for 2 months. Nine subgingival plaque samples/subject were analysed by checkerboard DNA–DNA hybridization for 40 bacterial species at baseline, 3, 6 and 12 months post-therapy.

RESULTS

At 12 months, the antibiotic-treated groups harboured lower mean counts and proportions of key periodontal pathogens than the SRP group (p < 0.05). These benefits were observed at initially deep and shallow sites. Initial reductions in periodontal pathogens obtained with SRP partially rebound after 12 months. CHX rinsing enhanced the microbiological effects of the MTZ + AMX treatment in shallow sites.

CONCLUSION

The adjunctive use of MTZ and MTZ + AMX results in a greater reduction in the levels of periodontal pathogens in generalized ChP subjects compared to SRP alone.

Non-surgical periodontal therapy with systemic antibiotics in patients with untreated chronic periodontitis: a systematic review and meta-analysis

OBJECTIVE

The purpose of this meta-analysis is to evaluate the effectiveness of different systemic antibiotics in combination with scaling and root planing (SRP) when compared to SRP alone in patients with untreated chronic periodontitis.

BACKGROUND

Although chronic periodontitis is mostly treated without adjunctive systemic antibiotics, some recent meta-analyses have shown clinical benefit for some systemic antibiotics when used as an adjunct to SRP. However, there is a wide variety of systemic antibiotic regimens used today. It remains unclear if the selected type of systemic antibiotic influences the magnitude of clinical benefit.

MATERIAL AND METHODS

The MEDLINE-PubMed database was searched from their earliest records through May 16, 2013. Several journals were hand searched and some authors were contacted for additional information. Outcome measures analysed were mean bleeding on probing change, mean clinical attachment level gain and mean probing pocket depth reduction. Extracted data were pooled using a random effect model. Weighted mean differences were calculated and heterogeneity was assessed.

RESULTS

The search yielded 281 abstracts. Ultimately, 95 studies were selected, describing 43 studies meeting the eligibility criteria. Systemic antibiotics showed a significant (p < 0.05) additional pocket depth reduction for moderate (at 3 mo 0.27 mm ± 0.09, at 6 mo 0.23 mm ± 0.10 and at 12 mo 0.25 mm ± 0.27) and deep pockets (at 3 mo 0.62 mm ± 0.17, at 6 mo 0.58 mm ± 0.16 and at 12 mo 0.74 mm ± 0.30). Statistically, no specific type of antibiotic was superior over another. However, when analysing the clinical data for initially moderate pockets or deep pockets, some trends became apparent.

CONCLUSION

Systemic antibiotics combined with SRP offer additional clinical improvements compared to SRP alone. Although there were no statistically significant differences, there was a trend that for initially moderate and deep pockets, metronidazole or metronidazole combined with amoxicillin, resulted in clinical improvements that were more pronounced over doxycycline or azithromycin. Additionally, there was a trend that the magnitude of the clinical benefit became smaller over time (1 year).

Additional effects of homeopathy on chronic periodontitis: a 1-year follow-up randomized clinical trial

BACKGROUND AND OBJECTIVE

The aim of this study was test the hypothesis that homeopathy (H) enhances the effects of scaling and root planing (SRP) in patients with chronic periodontitis (CP).

MATERIALS AND METHODS

50 patients with CP were randomly allocated to one of two treatment groups: SRP (C-G) or SRP + H (H-G). Assessments were made at baseline and after 3 and 12 months of treatments. The local and systemic responses to the treatments were evaluated by clinical and serologic parameters, respectively.

RESULTS

Both groups displayed significant improvements, however, using clinical attachment gain and reductions in HDL, LDL and Total Cholesterol, Triglycerides, Glucose and Uric acid, from baseline to 1 year, as criteria for treatment success, H-G performed significantly better than C-G.

CONCLUSION

The findings of this 1-year follow-up randomized clinical trial suggest that homeopathic medicines, as an adjunctive to SRP, can provide significant local and systemic improvements for CP patients.

Metronidazole and amoxicillin as adjuncts to scaling and root planing for the treatment of type 2 diabetic subjects with periodontitis: 1-year outcomes of a randomized placebo-controlled clinical trial

AIM

To evaluate the clinical and microbiological effects of the use of metronidazole (MTZ) + amoxicillin (AMX) as adjuncts to scaling and root planing (SRP) for the treatment of chronic periodontitis (ChP) in type 2 diabetic subjects.

MATERIAL AND METHODS

Fifty-eight type 2 diabetic subjects (n = 29/group) with generalized ChP were randomly assigned to receive SRP alone or with MTZ [400 mg/thrice a day (TID)]+AMX (500 mg/TID) for 14 days. Subgingival biofilm samples were analyzed by qPCR for the presence of seven periodontal pathogens. Subjects were monitored at baseline, 3, 6 and 12 months post-therapies.

RESULTS

The group receiving SRP+MTZ+AMX presented greater mean probing depth (PD) reduction and clinical attachment gain, a lower number of sites with PD ≥5 mm (primary outcome variable) and a reduced number of subjects with ≥9 of these residual pockets than the control group at 1-year post-therapy (p < 0.05). The antibiotic-treated group also presented reduced levels and greater decreases of the three red complex species, Eubacterium nodatum and Prevotella intermedia, compared to the control group at 1 year (p < 0.05).

CONCLUSIONS

The adjunctive use of MTZ+AMX significantly improved the clinical and microbiological outcomes of SRP in the treatment of type 2 diabetic subjects with ChP.

Treatment of aggressive periodontitis

Despite etiological differences between aggressive and chronic periodontitis, the treatment concept for aggressive periodontitis is largely similar to that for chronic periodontitis. The goal of treatment is to create a clinical condition that is conducive to retaining as many teeth as possible for as long as possible. When a diagnosis has been made and risk factors have been identified, active treatment is commenced. The initial phase of active treatment consists of mechanical debridement, either alone or supplemented with antimicrobial drugs. Scaling and root planing has been shown to be effective in improving clinical indices, but does not always guarantee long-term stability. Antimicrobials can play a significant role in controlling aggressive periodontitis. Few studies have been published on this subject for localized aggressive periodontitis, but generalized aggressive periodontitis has been subject to more scrutiny. Studies have demonstrated that systemic antibiotics as an adjuvant to scaling and root planing are more effective in controlling disease compared with scaling and root planing alone or with supplemental application of local antibiotics or antiseptics. It has also become apparent that antibiotics ought to be administered with, or just after, mechanical debridement. Several studies have shown that regimens of amoxicillin combined with metronidazole or regimens of clindamycin are the most effective and are preferable to regimens containing doxycycline. Azithromycin has been shown to be a valid alternative to the regimen of amoxicillin plus metronidazole. A limited number of studies have been published on surgical treatment in patients with aggressive periodontitis, but the studies available show that the effect can be comparable with the effect on patients with chronic periodontitis, provided that proper oral hygiene is maintained, a strict maintenance program is followed and modifiable risk factors are controlled. Both access surgery and regenerative techniques have shown good results in patients with aggressive periodontitis. Once good periodontal health has been obtained, patients must be enrolled in a strict maintenance program that is directed toward controlling risk factors for disease recurrence and tooth loss. The most significant risk factors are noncompliance with regular maintenance care, smoking, high gingival bleeding index and poor plaque control. There is no evidence to suggest that daily use of antiseptic agents should be part of the supportive periodontal therapy for aggressive periodontitis.

Surgical and nonsurgical periodontal therapy. Learned and unlearned concepts

This review aims to highlight concepts relating to nonsurgical and surgical periodontal therapy, which have been learned and unlearned over the past few decades. A number of treatment procedures, such as gingival curettage and aggressive removal of contaminated root cementum, have been unlearned. Advances in technology have resulted in the introduction of a range of new methods for use in nonsurgical periodontal therapy, including machine-driven instruments, lasers, antimicrobial photodynamic therapy and local antimicrobial-delivery devices. However, these methods have not been shown to offer significant benefits over and above nonsurgical debridement using hand instruments. The method of debridement is therefore largely dependent on the preferences of the operator and the patient. Recent evidence indicates that specific systemic antimicrobials may be indicated for use as adjuncts to nonsurgical debridement in patients with advanced disease. Full-mouth disinfection protocols have been proven to be a relevant treatment option. We have learned that while nonsurgical and surgical methods result in similar long-term treatment outcomes, surgical therapy results in greater probing-depth reduction and clinical attachment gain in initially deep pockets. The surgical technique chosen seems to have limited influence upon changes in clinical attachment gain. What has not changed is the importance of thorough mechanical debridement and optimal plaque control for successful nonsurgical and surgical periodontal therapy.

Antibiotic prescribing in general dental practice

The purpose of this paper is to review the principles of antibiotic prescribing in light of the increasing worldwide problem of antibiotic resistance and the evidence of inappropriate use of antibiotics in dentistry. Guidance based on a review of the scientific evidence and recommended good practice for prescribing antibiotics in dental practice will be given.