Kinetics of spiramycin/metronidazole (Rodogyl) in human gingival crevicular fluid, saliva and blood

Clinical and microbiological efficacy of intra-pocket application of diode laser in grade C periodontitis: a randomized controlled clinical trial

BACKGROUND

Periodontitis is a microbially induced disease destroying structures anchoring teeth to jaw bones. Although metronidazole in combination with spiramycin is the effective conventional treatment of stage III grade C periodontitis, it has several systemic side effects. Laser therapy is widely used nowadays as an adjunct to scaling and root planing (SRP) to modulate inflammatory host response and eradicate microbes, due to bactericidal and detoxifying effects. Since microbiological analysis is one of the diagnostic methods identifying periodontal risk; our research aimed to investigate the efficacy of intra-pocket application of diode laser (980 nm) versus antibiotic therapy in enhancing clinical and microbiological parameters in stage III grade C periodontitis.

METHODS

A randomized controlled clinical trial was conducted on fifty patients with stage III grade C periodontitis, divided equally into two groups. We managed test group by SRP with intra-pocket application of diode laser (980 nm) and the control group by SRP with systemic antibiotic administration (spiramycin and metronidazole). Then, we measured periodontal pocket depth (PPD) and clinical attachment loss (CAL) for both groups, before treatment (baseline), four and twelve weeks after. Moreover, we collected gingival crevicular fluid from both groups at baseline, four and twelve weeks after treatment and analyzed by real-time polymerase chain reaction to detect the relative count of Aggregatibacter actinomycetemcomitans and Porhyromonas gingivalis.

RESULTS

Compared to baseline, all assessed clinical and microbiological parameters attested improvement at the end of the study period in each group individually with no significant difference between the two studied groups. Although, at twelve weeks, flare up of bacterial levels was detected with systemic antibiotic administration.

CONCLUSION

Laser therapy can be considered as an effective treatment modality in stage III grade C periodontitis, avoiding the systemic antibiotic side effects and solving the recurrence problems due to bacterial resistance by long term usage.

TRIAL REGISTRATION

NCT05222737 retrospectively on 03/02/2022, Clinicaltrial.gov.

Europe's contribution to the evaluation of the use of systemic antimicrobials in the treatment of periodontitis

This narrative review celebrates Europe's contribution to the current knowledge on systemically administered antimicrobials in periodontal treatment. Periodontitis is the most frequent chronic noncommunicable human disease. It is caused by dysbiotic bacterial biofilms and is commonly treated with subgingival instrumentation. However, some sites/patients do not respond adequately, and its limitations and shortcomings have been recognized. This has led to the development of alternative or adjunctive therapies. One is the use of antimicrobials to target bacteria in subgingival biofilms in the periodontal pocket, which can be targeted directly through the pocket entrance with a locally delivered antibiotic or systemically by oral, intravenous, or intramuscular methods. Since the early 20th century, several studies on systemic antibiotics have been undertaken and published, especially between 1990 and 2010. Europe's latest contribution to this topic is the first European Federation of Periodontology, S3-level Clinical Practice Guideline, which incorporates recommendations related to the use of adjuncts to treat stage I-III periodontitis. Understanding the etiopathogenesis of periodontal diseases, specifically periodontitis, has influenced the use of systemic periodontal antibiotic therapy. Randomized clinical trials and systematic reviews with meta-analyses have demonstrated the clinical advantages of adjunctive systemic antimicrobials. However, current recommendations are restrictive due to concerns about antibiotic misuse and the increase in microbial antibiotic resistance. European researchers have contributed to the use of systemic antimicrobials in the treatment of periodontitis through clinical trials and by providing rational guidelines. Nowadays, European researchers are exploring alternatives and directing clinical practice by providing evidence-based guidelines to limit the use of systemic antimicrobials.

Development and Optimization of HPLC Analysis of Metronidazole, Diloxanide, Spiramycin and Cliquinol in Pharmaceutical Dosage Forms Using Experimental Design

A new simple, sensitive, rapid and accurate gradient reversed-phase high-performance liquid chromatography with photodiode array detector (RP-HPLC-DAD) was developed and validated for simultaneous analysis of Metronidazole (MNZ), Spiramycin (SPY), Diloxanidefuroate (DIX) and Cliquinol (CLQ) using statistical experimental design. Initially, a resolution V fractional factorial design was used in order to screen five independent factors: the column temperature (°C), pH, phosphate buffer concentration (mM), flow rate (ml/min) and the initial fraction of mobile phase B (%). pH, flow rate and initial fraction of mobile phase B were identified as significant, using analysis of variance. The optimum conditions of separation determined with the aid of central composite design were: (1) initial mobile phase concentration: phosphate buffer/methanol (50/50, v/v), (2) phosphate buffer concentration (50 mM), (3) pH (4.72), (4) column temperature 30°C and (5) mobile phase flow rate (0.8 ml min^-1). Excellent linearity was observed for all of the standard calibration curves, and the correlation coefficients were above 0.9999. Limits of detection for all of the analyzed compounds ranged between 0.02 and 0.11 μg ml^-1; limits of quantitation ranged between 0.06 and 0.33 μg ml^-1 The proposed method showed good prediction ability. The optimized method was validated according to ICH guidelines. Three commercially available tablets were analyzed showing good % recovery and %RSD.

Comparative artificial neural network and partial least squares models for analysis of Metronidazole, Diloxanide, Spiramycin and Cliquinol in pharmaceutical preparations

Metronidazole (MNZ) is a widely used antibacterial and amoebicide drug. Therefore, it is important to develop a rapid and specific analytical method for the determination of MNZ in mixture with Spiramycin (SPY), Diloxanide (DIX) and Cliquinol (CLQ) in pharmaceutical preparations. This work describes simple, sensitive and reliable six multivariate calibration methods, namely linear and nonlinear artificial neural networks preceded by genetic algorithm (GA-ANN) and principle component analysis (PCA-ANN) as well as partial least squares (PLS) either alone or preceded by genetic algorithm (GA-PLS) for UV spectrophotometric determination of MNZ, SPY, DIX and CLQ in pharmaceutical preparations with no interference of pharmaceutical additives. The results manifest the problem of nonlinearity and how models like ANN can handle it. Analytical performance of these methods was statistically validated with respect to linearity, accuracy, precision and specificity. The developed methods indicate the ability of the previously mentioned multivariate calibration models to handle and solve UV spectra of the four components' mixtures using easy and widely used UV spectrophotometer.

Concentrations of metronidazole in human plasma and saliva after tablet or gel administration

OBJECTIVES

The aim of this study was to determine the pharmacokinetic profile of metronidazole (Mtz) tablet and to compare Mtz gel and tablet concentrations in both blood plasma and saliva.

METHODS

In this randomized cross-over study with a 1-week washout period, 13 volunteers randomly received one (a single oral dose of 750 mg Mtz (Flagyl®--tablet) and 2) 3 g of 15% Mtz benzoate gel (applied by using a dental tray). The HPLC with ultraviolet detection was used to quantify plasma and saliva concentrations of Mtz. The pharmacokinetic parameters (PPs) areas under the curves from 0 to 48 h (AUC0-48) and from 0 to infinity (AUC0-∞), the maximum plasma concentration (C(max)), the time to C(max), volume of distribution and renal clearance were determined for Mtz tablet.

KEY FINDINGS

Considering the Mtz tablet, plasma showed higher Mtz concentration from 6 to 24 h after drug administration and the highest values concerning AUC0-48 h and AUC0-∞ than those obtained in saliva (P < 0.05). No significant differences were observed between plasma and saliva concentrations for Mtz gel.

CONCLUSIONS

The study showed that some PPs were higher in plasma (P < 0.05) than in saliva concerning Mtz tablet. Gel formulation had similar Mtz bioavailability in plasma and saliva resulting in systemic absorption.

Timing Affects the Clinical Outcome of Adjunctive Systemic Antibiotic Therapy for Generalized Aggressive Periodontitis

BACKGROUND

Systemic antibiotics improve the outcome of scaling and root planing (SRP) in patients exhibiting severe periodontitis. This study evaluated the influence of timing of adjunctive systemic antibiotics in the sequence of periodontal therapy.

METHODS

Two cohorts of patients with generalized aggressive periodontitis and treated by SRP, adjunctive antibiotics, and supportive periodontal therapy (SPT) were analyzed retrospectively. Cohort A (17 patients; 36 +/- 5 years of age) received systemic amoxicillin/metronidazole immediately after SRP ("immediate"); cohort B (17 patients; 36 +/- 4 years of age) received the same regimen 3 months after SRP, following SPT, including subgingival reinstrumentation ("late"). Clinical parameters, including probing depth (PD), relative attachment level (RAL), bleeding on probing (BOP), and suppuration, were recorded with a pressure-sensitive electronic probe at baseline and 3 and 6 months after SRP.

RESULTS

Significant time*group interactions were found for all clinical parameters except BOP, i.e., timing of antibiotic therapy affected the course of clinical changes over time. Immediate antibiotic therapy produced significantly higher initial changes (0 to 3 months) in PD and RAL. Late antibiotic therapy at 3 months resulted in additional significant improvements in all clinical parameters between 3 and 6 months. In initially deep sites (baseline PD >6 mm), improvements in PD and RAL over 6 months were significantly higher with immediate antibiotic therapy compared to late antibiotic therapy.

CONCLUSION

Within the limits of a retrospective analysis, these findings indicate that administration of amoxicillin/metronidazole immediately after initial SRP provides more PD reduction and RAL "gain" in initially deep sites than late administration at SPT with reinstrumentation after 3 months.

Incidence of antibiotic prescribing in dental practice in Norway and its contribution to national consumption

OBJECTIVES

To assess dentistry-based utilization of the 11 antibiotics prescribed by dentists in Norway and its relative contribution to national outpatient consumption and to determine the relationship between numbers of prescriptions and the consumption of these antibiotics.

METHODS

Data on national antibiotic prescriptions by dentists in 2004 and 2005 were used. Consumption of the antibiotics was expressed using WHO defined daily doses (DDDs), DDDs per 1000 inhabitants per day (DIDs) and numbers of prescriptions per 1000 inhabitants (PIDs).

RESULTS

Analysis of 268,834 prescriptions issued by 4765 dentists showed that the dentists' prescriptions contributed 8% of the total national consumption of the 11 antibiotics and 13.5%, 2.8% and 1.2% of the national beta-lactam penicillins, macrolides and lincosamides and tetracyclines utilization, respectively. The dentists' contributions to the national phenoxymethylpenicillin, spiramycin and metronidazole consumptions were considerably higher (> or =13.2%) than for the other prescribed antibiotics (< or =8.6%). There was a strong positive correlation between numbers of DDDs and numbers of prescriptions and between DIDs and numbers of PIDs.

CONCLUSIONS

Reliance of Norwegian dentists on phenoxymethylpenicillin as their first choice suggests a low prevalence of antibiotic resistance among oral bacteria in Norway. Norwegian dentists prefer to prescribe narrow-spectrum antibiotics; their prescribing is conservative and relatively low compared with that of physicians.

Plasma and gingival crevicular fluid phenytoin concentrations as risk factors for gingival overgrowth

BACKGROUND

Gingival enlargement is one of the side effects associated with the administration of phenytoin. The mechanism by which phenytoin induces gingival enlargement is not well understood. This study was conducted to investigate the relationship between plasma and gingival crevicular fluid (GCF) phenytoin concentrations and the degree of gingival overgrowth in patients with similar gingival and plaque indices and also to determine the risk factors for gingival enlargement.

METHODS

Eighteen patients taking phenytoin in regular doses > or =6 months prior to the investigation participated in the study. Gingival enlargement was evaluated with two indices to score vertical and horizontal overgrowth. The gingival index (GI), plaque index (PI), gingival bleeding time index (GBTI), probing depth (PD), and clinical attachment level (CAL) were also evaluated. GCF and plasma phenytoin concentrations were determined by using high-performance liquid chromatography (HPLC).

RESULTS

There was no significant difference between responders and non-responders for PD, CAL, PI, GI, and GBTI. Phenytoin was detected in all of the GCF and plasma samples using the HPLC analysis method. The mean concentration of phenytoin in GCF was significantly greater than the concentration of phenytoin in plasma. No significant difference was observed for the concentration of GCF phenytoin between responders and non-responders. However, the concentration of plasma phenytoin was significantly higher in responders than non-responders.

CONCLUSION

This study showed that plasma phenytoin level appeared to be a risk factor for phenytoin-induced gingival overgrowth.

Simultaneous determination of metronidazole and spiramycin I in human plasma, saliva and gingival crevicular fluid by LC–MS/MS

An analytical validation of a new liquid chromatographic-mass spectrometric (LC-MS/MS) method for simultaneous determination of metronidazole and spiramycin I concentrations in human plasma, saliva and gingival crevicular fluid (GCF) is presented. Ornidazole was used as an internal standard, and sample pre-treatment consisted of a liquid-liquid extraction. Chromatographic separation was achieved on a 5 microm Kromasil C18 column (150 mm x 4.6 mm i.d., particle size 5 microm), with a gradient using acetonitrile, water and formic acid at a flow rate of 0.9 ml/min. The methods were validated in terms of intra- and inter-batch precision (<7.1% in plasma, 12% in saliva and 9.2% in GCF, respectively) and accuracy (within +/-8.7% in plasma, within +/-8.7%, except LDQ level within +/-15.4% in saliva and within +/-10.7% in GCF), linearity, specificity, recovery (extraction efficiency), matrix effect, dilution process, stability in human plasma and saliva after three freeze-thaw cycles, stability in human plasma and saliva at ambient temperature and stability of the extracts in the automatic injector of the HPLC system. The methods are applicable for accurate and simultaneous monitoring of the plasma, saliva and gingival crevicular fluid levels of metronidazole and spiramycin I from pharmacokinetic studies.

Concentrations and in vivo antibacterial activity of spiramycin and metronidazole in patients with periodontitis treated with high-dose metronidazole and the spiramycin/metronidazole combination

OBJECTIVES

Previous studies have shown that metronidazole, alone or in combination with spiramycin (250 mg/1 500 000 units, three times/day), is an effective treatment for active periodontitis, although the dose of metronidazole currently used (750 mg/day) could provide concentrations in gingival crevice fluid that are too low for the MICs of the involved pathogens. This study tested the in vivo antibacterial efficacy of the currently used metronidazole dose (as contained in the fixed spiramycin/metronidazole combination) in patients with an active periodontitis, and of a high dose (1500 mg/day) of metronidazole alone.

METHODS

We measured the MICs of spiramycin and metronidazole for the recovered pathogens and the gingival crevice fluid antibiotic concentrations of both antibiotics, and attempted to correlate them with bacterial eradication.

RESULTS

The concentrations of metronidazole consistently exceeded the MICs for the pathogens isolated in the corresponding sites, even at the usual metronidazole (250 mg three times/day) dose. All the bacterial species were eradicated during treatment and at follow-up, although Fusobacterium spp. eradicated during treatment reappeared in a majority of the cases at follow-up, 30 days after treatment, in both groups.

CONCLUSIONS

The results of antibiotic therapy with metronidazole or the spiramycin/metronidazole combination are consistent with their in vitro antibacterial activity and with the local antibiotic concentrations; they suggest that the currently used metronidazole dose (250 mg, three times/day) alone or as part of the spiramycin/metronidazole combination, could be sufficient for the treatment of active periodontitis.

Antibiotic treatment of incipient drug-induced gingival overgrowth in adult renal transplant patients

BACKGROUND

Drug-induced gingival overgrowth (GO) remains a challenge in periodontics. Partial and total regressions of this GO have been reported after a short course of antibiotics.

METHODS

We conducted a double-blinded controlled randomised study to determine the effect of metronidazole (MNZ) or azithromycin (AZM) on the regression of incipient cyclosporin A-induced GO in 40 adult renal transplanted patients. The quantitation of the GO was performed with Image Digital Analysis.

RESULTS

None of the patients with GO showed complete remission after 30 days. The pretreatment GO index was 0.895 +/- 0.16 in the metronidazole treatment group (MNZ group, n = 13), 0.932 +/- 0.11 in the azithromycin treatment group (AZM group, n = 14), and 1.073 +/- 0.32 in the controls (placebo group, n = 13). At the end of the study (30 days), the GO index score was lower in 54.4% and 62.3% of the MNZ and AZM groups, respectively, and the mean score differences were statistically significant between the groups (0.897 +/- 0.28, MNZ group vs. 0.909 +/- 0.15, AZM group vs. 1.130 +/- 0.3, placebo group, P < 0.05 ANOVA).

CONCLUSIONS

A 7-day course of MNZ or AZM does not induce remission of CsA-induced GO, although it acts on concomitant bacterial over-infection and gingival inflammation.

In vitro antimicrobial susceptibility of oral strains of Actinobacillus actinomycetemcomitans to seven antibiotics

BACKGROUND/AIMS

Periodontal infections with Actinobacillus actinomycetemcomitans seem to be refractory to conventional therapy. The aim of the present study was to test the in vitro susceptibilities of A. actinomycetemcomitans strains to a panel of seven orally administrable antibiotics.

METHODS

A total of 60 isolates of A. actinomycetemcomitans recovered from 43 individuals with gingivitis or periodontitis were tested. In addition, laboratory strains UP-6 and JP2 were analysed. The E-test was employed in order to determine minimal inhibitory concentrations (MIC) of antibiotics ampicillin/sulbactam, roxithromycin, azithromycin, doxycycline, metronidazole, ciprofloxacin, and moxifloxacin.

RESULTS

A. actinomycetemcomitans was highly susceptible to both fluoro-quinolones (MIC90 of 0.006 microgram/mL of ciprofloxacin and 0.032 microgram/mL of moxifloxacin). Good susceptibilities were found for ampicillin/sulbactam and doxycycline (MIC90 of 0.75 microgram/mL and 1 microgram/mL, respectively), and moderate susceptibilities for azithromycin (MIC90 of 3 microgram/mL). Most strains were resistant to metronidazole and roxithromycin. Cluster analysis revealed two larger clusters of A. actinomycetemcomitans strains with the smaller cluster assembling isolates with significantly higher MICs of most antibiotics.

CONCLUSIONS

Due to reported favourable pharmacokinetics, the fluoro-quinolone moxifloxacin appeared to be a promising candidate for adjunctive systemic antibiotic therapy in periodontal infections with A. actinomycetemcomitans.

In vitro study of the effect of titanium on porphyromonas gingivalis in the presence of metronidazole and spiramycin

Septic peri-implantitis is the main clinical complication encountered following the insertion of titanium implants. It may be resistant to conventional antibiotic treatments. Reports in the literature about antibiotic behavior in the presence of titanium remain controversial. They vary from a bacteriostat to a decreased effect of antibiotic. This study examined, in vitro, the viability of Porphyromonas gingivalis, frequently associated with periodontal diseases, in the presence of titanium and antibiotics (spiramycin and metronidazole alone or in combination). Viability of P. gingivalis was determined, versus a standard curve using the Live/dead Baclight Bacteria Viability Kit on 96 well microplates. The results of 48 experiments (60 measurements each) were compiled in a database and compared to each other using the chi2p < 0.05 test. When used alone, titanium enhanced bacterial growth as the nickel-chrome control. However, when titanium was used in the presence of antibiotics, antibiotics kept their own effects. Even more, titanium was shown to potentialize the effect of metronidazole. The strengthening of effectiveness of metronidazole by titanium may be due to the oxidation potential of the metal. This chemical property could explain the conflicting data reported in the literature.