Effects of metronidazole on periodontal treatment needs

Systemic azithromycin versus amoxicillin/metronidazole as an adjunct in the treatment of periodontitis: a systematic review and meta-analysis

BACKGROUND

The use of systemic azithromycin (AZT) and amoxicillin/metronidazole (AMX/MTZ) as adjuncts provided additional clinical and microbiological benefits over subgingival instrumentation alone. However, the superiority of one antibiotic regimen over another has not been proven. Therefore, the aim of this systematic review and meta-analyses was to evaluate the clinical efficacy and safety of subgingival instrumentation (SI) in conjunction with the systemic use of AZT or AMX/MTZ for the treatment of periodontitis from current published literature.

METHODS

Electronic databases were searched to identify randomized controlled trials (RCTs), controlled clinical trials, prospective and retrospective human studies that compared the adjunctive use of systemic AZT to AMX/MTZ with SI in the treatment of periodontitis. The eligibility criteria were defined based on the participant (who had periodontitis), intervention (SI with adjunctive use of systemic AZT), comparison (SI with adjunctive use of systemic AMX/MTZ), outcomes (primary outcome: changes in probing pocket). The risk of bias was assessed using the Cochrane Collaboration's Risk of Bias tool. Data were analysed using a statistical software program.

RESULTS

Five studies with 151 participants with periodontitis were included in the present review. Of these, 74 participants received adjunctive AZT, while the remaining participants received AMX/MTZ as an adjunct to SI. The adjunctive use of AZT and AMX/MTZ had comparable changes in probing pocket depths at 1-3 months with no statistically significant difference (mean difference (MD) 0.01; 95% CI -0.20 to 0.22; P = 0.94). The adjunctive use of AZT had significantly fewer number of residual sites with probing pocket depths of ≥5 mm at 1-3 months compared to the adjunctive use of AMX/MTZ (MD -3.41; 95% CI -4.73 to -2.10; P < 0.0001). The prevalence rates of adverse events among participants who received AZT and AMX/MTZ were 9.80% and 14.8%, respectively. The meta-analysis showed that the difference between the two groups was not statistically significant (risk ratio 0.69; 95% CI 0.28 to 1.72; P = 0.43).

CONCLUSIONS

Within the limitation of this review, there was no superiority between AZT and AMX/MTZ in terms of mean changes in probing pocket depths, clinical attachment level, bleeding on probing at 1-3 months. AZT seem to be associated with less sites with residual probing pocket depths of ≥5 mm at 1-3 months and fewer adverse events compared with AMX/MTZ. © 2023 Australian Dental Association.

Metronidazole promotes oxidative stress and DNA fragmentation-mediated myocardial injury in albino mice

The purpose of the present study was to investigate the cardiotoxic effects of Metronidazole (Mtz) in albino mice. The mice were divided into four experimental groups: Gp.I (control group): saline, Gp.II:125 mg/kg b.w Mtz, Gp.III:250 mg/kg b.w, Gp.IV:500 mg/kg b.w Mtz. Heart weight ratio, markers of cardiac injury, markers of oxidative stress, histopathological examinations, DNA fragmentation and spectral analysis were used to determine cardiotoxicity. Administration of 125-500 mg/kg Mtz caused an increase in heart weight and a decrease in body weight. Administration of 500 mg/kg Mtz increased heart weight by 35.5% and decreased body weight by 21.9% compared with control. Mtz-treated mice showed a significant increase in cardiac injury biomarkers and serious alterations in cardiac oxidative stress markers. Histopathological changes of cardiac tissues observed in mice treated with Mtz include myocardial hypertrophy, fibrosis, myocarditis, separation of the muscle fibers, congestion-narrowing in vessels, necrosis, myocardium-vacuolation, myocytolysis, myocyte degeneration, nuclear aggregation, cytoplasmic fragmentation and prevalent nuclei. Mtz treatment already resulted in a significant decrease in the percentage of head DNA and an increase in the percentage of tail DNA. The most striking tail formation among the Mtz-treated groups was observed in the group receiving 500 mg/kg Mtz. In the presence of Mtz, there was a hypochromic shift in the absorption spectrum of DNA, and the potential DNA-Mtz interaction was found to occur in the intercalation mode. These results show that Mtz used against anaerobic bacteria and protozoa in gastrointestinal infections can cause severe cardiotoxic findings in albino mice and cause fragmentation in DNA.

Five-year radiological findings from a randomized controlled trial of four periodontitis treatment strategies

Radiographic findings from long-term studies of periodontitis treatment have rarely been reported. Although bone destruction is a prominent feature of periodontitis, the long-term effect on alveolar bone levels of different treatment strategies, with or without adjunctive metronidazole (MTZ), has not been reported. We investigated the 5-year radiographic outcome of therapy in patient groups treated with conventional scaling and root planing (SRP) or same-day full-mouth disinfection (FDIS), with or without adjunctive MTZ. Following a 3-month oral hygiene phase, 184 periodontitis patients were randomly allocated to one of four treatment regimens: (i) FDIS+MTZ; (ii) FDIS+placebo; (iii) SRP+MTZ; or (iv) SRP+placebo. Following active treatment, patients received biannual maintenance. In total, 161 patients (87.5%) completed the 5-year follow-up examination, at which the radiographic bone level (RBL), clinical attachment level, probing pocket depth, presence of plaque, and bleeding were recorded again. At the 5-year follow up examination, minor radiological bone loss was observed in the intervention groups FDIS+placebo, SRP+MTZ, and SRP+placebo; by contrast, the FDIS+MTZ group did not show any change in RBL. Full-mouth disinfection did not generally perform better than conventional SRP performed over a period of 2 to 4 weeks.

Combined Release of Antiseptic and Antibiotic Drugs from Visible Light Polymerized Biodegradable Nanocomposite Hydrogels for Periodontitis Treatment

The in situ application of the combination of different types of drugs revolutionized the area of periodontal therapy. The purpose of this study was to develop nanocomposite hydrogel (NCHG) as a pH-sensitive drug delivery system. To achieve local applicability of the NCHG in dental practice, routinely used blue-light photopolymerization was chosen for preparation. The setting time was 60 s, which resulted in stable hydrogel structures. Universal Britton–Robinson buffer solutions were used to investigate the effect of pH in the range 4–12 on the release of drugs that can be used in the periodontal pocket. Metronidazole was released from the NCHGs within 12 h, but chlorhexidine showed a much longer elution time with strong pH dependence, which lasted more than 7 days as it was corroborated by the bactericidal effect. The biocompatibility of the NCHGs was proven by Alamar-blue test and the effectiveness of drug release in the acidic medium was also demonstrated. This fast photo-polymerizable NCHG can help to establish a locally applicable combined drug delivery system which can be loaded with the required amount of medicines and can reduce the side effects of the systemic use of drugs that have to be used in high doses to reach an ideal concentration locally.

Adjunctive systemic antimicrobials for the non-surgical treatment of periodontitis

BACKGROUND

Systemic antimicrobials can be used as an adjunct to mechanical debridement (scaling and root planing (SRP)) as a non-surgical treatment approach to manage periodontitis. A range of antibiotics with different dosage and combinations are documented in the literature. The review follows the previous classification of periodontitis as all included studies used this classification.

OBJECTIVES

To assess the effects of systemic antimicrobials as an adjunct to SRP for the non-surgical treatment of patients with periodontitis.

SEARCH METHODS

Cochrane Oral Health's Information Specialist searched the following databases to 9 March 2020: Cochrane Oral Health's Trials Register, CENTRAL, MEDLINE, and Embase. The US National Institutes of Health Ongoing Trials Register ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) which involved individuals with clinically diagnosed untreated periodontitis. Trials compared SRP with systemic antibiotics versus SRP alone/placebo, or with other systemic antibiotics.

DATA COLLECTION AND ANALYSIS

We selected trials, extracted data, and assessed risk of bias in duplicate. We estimated mean differences (MDs) for continuous data, with 95% confidence intervals (CIs). We assessed the certainty of the evidence using GRADE.

MAIN RESULTS

We included 45 trials conducted worldwide involving 2664 adult participants. 14 studies were at low, 8 at high, and the remaining 23 at unclear overall risk of bias. Seven trials did not contribute data to the analysis. We assessed the certainty of the evidence for the 10 comparisons which reported long-term follow-up (≥ 1 year). None of the studies reported data on antimicrobial resistance and patient-reported quality of life changes. Amoxicillin + metronidazole + SRP versus SRP in chronic/aggressive periodontitis: the evidence for percentage of closed pockets (MD -16.20%, 95% CI -25.87 to -6.53; 1 study, 44 participants); clinical attachment level (CAL) (MD -0.47 mm, 95% CI -0.90 to -0.05; 2 studies, 389 participants); probing pocket depth (PD) (MD -0.30 mm, 95% CI -0.42 to -0.18; 2 studies, 389 participants); and percentage of bleeding on probing (BOP) (MD -8.06%, 95% CI -14.26 to -1.85; 2 studies, 389 participants) was of very low certainty. Only the results for closed pockets and BOP showed a minimally important clinical difference (MICD) favouring amoxicillin + metronidazole + SRP. Metronidazole + SRP versus SRP in chronic/aggressive periodontitis: the evidence for percentage of closed pockets (MD -12.20%, 95% CI -29.23 to 4.83; 1 study, 22 participants); CAL (MD -1.12 mm, 95% CI -2.24 to 0; 3 studies, 71 participants); PD (MD -1.11 mm, 95% CI -2.84 to 0.61; 2 studies, 47 participants); and percentage of BOP (MD -6.90%, 95% CI -22.10 to 8.30; 1 study, 22 participants) was of very low certainty. Only the results for CAL and PD showed an MICD favouring the MTZ + SRP group. Azithromycin + SRP versus SRP for chronic/aggressive periodontitis: we found no evidence of a difference in percentage of closed pockets (MD 2.50%, 95% CI -10.19 to 15.19; 1 study, 40 participants); CAL (MD -0.59 mm, 95% CI -1.27 to 0.08; 2 studies, 110 participants); PD (MD -0.77 mm, 95% CI -2.33 to 0.79; 2 studies, 110 participants); and percentage of BOP (MD -1.28%, 95% CI -4.32 to 1.76; 2 studies, 110 participants) (very low-certainty evidence for all outcomes). Amoxicillin + clavulanate + SRP versus SRP for chronic periodontitis: the evidence from 1 study, 21 participants for CAL (MD 0.10 mm, 95% CI -0.51 to 0.71); PD (MD 0.10 mm, 95% CI -0.17 to 0.37); and BOP (MD 0%, 95% CI -0.09 to 0.09) was of very low certainty and did not show a difference between the groups. Doxycycline + SRP versus SRP in aggressive periodontitis: the evidence from 1 study, 22 participants for CAL (MD -0.80 mm, 95% CI -1.49 to -0.11); and PD (MD -1.00 mm, 95% CI -1.78 to -0.22) was of very low certainty, with the doxycycline + SRP group showing an MICD in PD only. Tetracycline + SRP versus SRP for aggressive periodontitis: we found very low-certainty evidence of a difference in long-term improvement in CAL for the tetracycline group (MD -2.30 mm, 95% CI -2.50 to -2.10; 1 study, 26 participants). Clindamycin + SRP versus SRP in aggressive periodontitis: we found very low-certainty evidence from 1 study, 21 participants of a difference in long-term improvement in CAL (MD -1.70 mm, 95% CI -2.40 to -1.00); and PD (MD -1.80 mm, 95% CI -2.47 to -1.13) favouring clindamycin + SRP. Doxycycline + SRP versus metronidazole + SRP for aggressive periodontitis: there was very low-certainty evidence from 1 study, 27 participants of a difference in long-term CAL (MD 1.10 mm, 95% CI 0.36 to 1.84); and PD (MD 1.00 mm, 95% CI 0.30 to 1.70) favouring metronidazole + SRP. Clindamycin + SRP versus metronidazole + SRP for aggressive periodontitis: the evidence from 1 study, 26 participants for CAL (MD 0.20 mm, 95% CI -0.55 to 0.95); and PD (MD 0.20 mm, 95% CI -0.38 to 0.78) was of very low certainty and did not show a difference between the groups. Clindamycin + SRP versus doxycycline + SRP for aggressive periodontitis: the evidence from 1 study, 23 participants for CAL (MD -0.90 mm, 95% CI -1.62 to -0.18); and PD (MD -0.80 mm, 95% CI -1.58 to -0.02) was of very low certainty and did not show a difference between the groups. Most trials testing amoxicillin, metronidazole, and azithromycin reported adverse events such as nausea, vomiting, diarrhoea, mild gastrointestinal disturbances, and metallic taste. No serious adverse events were reported.

AUTHORS' CONCLUSIONS

There is very low-certainty evidence (for long-term follow-up) to inform clinicians and patients if adjunctive systemic antimicrobials are of any help for the non-surgical treatment of periodontitis. There is insufficient evidence to decide whether some antibiotics are better than others when used alongside SRP. None of the trials reported serious adverse events but patients should be made aware of the common adverse events related to these drugs. Well-planned RCTs need to be conducted clearly defining the minimally important clinical difference for the outcomes closed pockets, CAL, PD, and BOP.

The Side Effects of the Most Commonly Used Group of Antibiotics in Periodontal Treatments

Antibiotic combinations are preferred for the treatment of periodontal diseases, with the aim of hitting the bacterial flora, according to its characteristics—aerobic, anaerobic, gram-negative, and gram-positive—with certain antibiotics that act on certain bacteria. The aim of this study is to analyze the side effects of the antibiotics used. Data on the side effects (preferably expressed in percentages) of some antibiotics, the favorites in periodontal recipes, are gathered from the literature. These data are listed according to the antibiotic used. In the case of providing a periodontal prescription, the patient is at risk of allergy (5%), nephritis (3%), hematological problems (2–2.5%), gastrointestinal problems (5.5%), disturbance in the nervous system (2%), allergic signs on the skin (5.5%), and problems with electrolytes displayed in lower percentages. Interaction with different medications is present in almost all cases. The influence on the body systems is 4% in total, the maximum value of which is expressed on the skin, and the minimum value is expressed in the nervous system. Cross allergies are at a high value because of the expressed structural similarity of antibiotics. Given a recipe, we have a balance of the percentage of side effects, the percentage of bacterial resistance, and the percentage of the success of the recommended dose of antibiotics.

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.

Is progression of periodontitis relevantly influenced by systemic antibiotics? A clinical randomized trial

AIM

We investigated the long-term impact of adjunctive systemic antibiotics on periodontal disease progression. Periodontal therapy is frequently supplemented by systemic antibiotics, although its impact on the course of disease is still unclear.

MATERIAL & METHODS

This prospective, randomized, double-blind, placebo-controlled multi-centre trial comprising patients suffering from moderate to severe periodontitis evaluated the impact of rational adjunctive use of systemic amoxicillin 500 mg plus metronidazole 400 mg (3x/day, 7 days) on attachment loss. The primary outcome was the percentage of sites showing further attachment loss (PSAL) ≥1.3 mm after the 27.5 months observation period. Standardized therapy comprised mechanical debridement in conjunction with antibiotics or placebo administration, and maintenance therapy at 3 months intervals.

RESULTS

From 506 participating patients, 406 were included in the intention to treat analysis. Median PSAL observed in placebo group was 7.8% compared to 5.3% in antibiotics group (Q25 4.7%/Q75 14.1%; Q25 3.1%/Q75 9.9%; p < 0.001 respectively).

CONCLUSIONS

Both treatments were effective in preventing disease progression. Compared to placebo, the prescription of empiric adjunctive systemic antibiotics showed a small absolute, although statistically significant, additional reduction in further attachment loss. Therapists should consider the patient's overall risk for periodontal disease when deciding for or against adjunctive antibiotics prescription.

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.

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).

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.

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.

Effect of periodontal therapy on the subgingival microbiota over a 2-year monitoring period. I. Overall effect and kinetics of change

AIM

To examine the 2-year post-therapy kinetics of change in the composition of subgingival biofilms.

MATERIAL AND METHODS

In this study, 178 chronic periodontitis subjects were recruited and clinically monitored at baseline, 3, 6, 12, 18 and 24 months after therapy. All subjects received scaling and root planing and 156 one or more of periodontal surgery, systemically administered amoxicillin + metronidazole or local tetracycline at pockets ≥5 mm. Subgingival biofilm samples taken from each subject at each time point were analysed for their content of 40 bacterial species using checkerboard DNA-DNA hybridization. The significance of changes in median species counts over time was sought using the Wilcoxon or Friedman tests and adjusted for multiple comparisons.

RESULTS

Mean counts were significantly reduced from baseline to 2 years for 30 of the 40 taxa. Marked reductions were observed for periodontal pathogens including Tannerella forsythia, Treponema denticola and Eubacterium nodatum. The kinetics of change differed from species to species. When data were subset according to baseline PD, patterns of change in the microbial profiles were generally similar.

CONCLUSION

Periodontal therapy leads to a rapid reduction in periodontal pathogens, followed by a slower reduction in other taxa that can be sustained for at least 2 years.

Further characterization of a bacteriocin produced by Lactobacillus paracasei HL32

AIMS

Purification, identification and partial characterization of bacteriocin produced by Lactobacillus paracasei HL32. It has been shown to have activity against Porphyromonas sp.

METHODS AND RESULTS

The purification of bacteriocin consisting of gel exclusion followed by anion exchange chromatography produced a single band upon an electrophoresis gel with a molecular weight corresponding to 56 kDa. The isolated protein contained 171 amino acids and the first 151 were sequenced. The bacteriocin contained a high percentage of cationic amino acids near the N-terminus, hydrophobic amino acids in the central region (Leu, Ile, Val, Phe, Trp and Gly) and hydrophilic residues (Ser, Asn and Gln) at the C-terminus. This structure did not match with that of previously reported bacteriocins. The antimicrobial activity of the bacteriocin was determined against some pathogens and normal microbiota (P. gingivalis, P. intermedia, T. forsythensis, S. salivarius and S. sanguinis) found in saliva and crevicular fluid. The bacteriocin was found to inhibit P. gingivalis at the minimum bactericidal concentration (MBC) of 0.14 mmol l(-1), but was found not to inhibit the other oral micro-organisms. The bacteriocin was found from transmission electron microscopy studies to cause pore formation in the cytoplasmic membranes of P. gingivalis at the pole and induce potassium efflux. Bacteriocin concentrations of two to four times of MBC were shown to induce haemolysis. The bacteriocin was heat-stable, surviving at 110 degrees C under pressure and possessed activity over a pH range of 6.8-8.5. Only a small reduction of activity was found to occur after incubation in biological fluids (saliva and crevicular fluid).

CONCLUSIONS

A novel bacteriocin has been identified that has selective activity against Porphyromonas sp. associated with periodontal disease.

SIGNIFICANCE AND IMPACT OF THE STUDY

The findings of this work gained the knowledge of specific antibacterial activity of bacteriocin against Porphyromonas gingivalis.

Antimicrobial therapy in periodontitis: the use of systemic antimicrobials against the subgingival biofilm

OBJECTIVES

The aim was to answer three relevant questions: can systemic antimicrobials be efficacious if the biofilm is not disrupted? Can the type of debridement of the subgingival biofilm impact upon the clinical outcomes of the adjunctive antimicrobial therapy? Is the efficacy of the adjunctive systemic antimicrobial therapy dependent on the quality of the debridement of the subgingival biofilm and the sequence debridement-antibiotic usage?

MATERIAL AND METHODS

Relevant papers were searched, critically analysed and their data were extracted.

RESULTS

For the first question, studies assessing susceptibility of bacteria in biofilms, and clinical studies evaluating systemic antimicrobials as monotherapy, were reviewed. For the second question, clinical studies comparing systemic antimicrobials as adjuncts to non-surgical debridement or to periodontal surgery and clinical trials using systemic antibiotics with periodontal surgery were evaluated. For the third question, a previous systematic review was updated.

CONCLUSION

If systemic antimicrobials are indicated in periodontal therapy, they should be adjunctive to mechanical debridement. There is not enough evidence to support their use with periodontal surgery. Indirect evidence suggests that antibiotic intake should start on the day of debridement completion, debridement should be completed within a short time (preferably <1 week) and with an adequate quality, to optimize the results.

Controlled-delivery chlorhexidine chip versus amoxicillin/metronidazole as adjunctive antimicrobial therapy for generalized aggressive periodontitis: a randomized controlled clinical trial

BACKGROUND

Subgingival application of chlorhexidine via a controlled-delivery device (CHX chip) improves the clinical outcome of scaling/root planing (SRP) in therapy for chronic periodontitis. Generalized aggressive periodontitis (GAP) is commonly treated with SRP and adjunctive antimicrobial medication. To date, the efficacy of CHX chips in GAP therapy has not been evaluated.

AIM

To compare SRP plus adjunctive CHX chip placement with SRP plus adjunctive systemic amoxicillin/metronidazole with regard to clinical efficacy in first-line therapy for GAP.

MATERIAL AND METHODS

Thirty-six GAP patients were treated with SRP and randomly with either placement of CHX chips or systemic amoxicillin/metronidazole. Clinical attachment level (CAL), probing depth (PD), bleeding on probing (BoP) and suppuration (Pus) were measured at baseline, 3 and 6 months after therapy.

RESULTS

CAL, PD, BoP and Pus were significantly reduced in both groups after 3 months. In the CHX chip group, PD significantly increased again between 3 and 6 months. Finally, amoxicillin/metronidazole patients presented significantly more CAL "gain", PD reduction and less remaining deep sites after 6 months. Pus remained detectable in CHX chip patients only.

CONCLUSIONS

In first-line non-surgical therapy for GAP, SRP plus adjunctive systemic amoxicillin/metronidazole was more efficacious in clinically relevant measures of outcome than SRP plus adjunctive placement of CHX chips.

Drug Concentration in Inflamed Periodontal Tissues After Systemically Administered Azithromycin

BACKGROUND

Azithromycin is an azalide antibiotic, effective against a wide range of oral bacteria including periodontopathic bacteria. Azithromycin is taken up by phagocytes and is released into inflamed tissue over time. The concentration of azithromycin in inflamed periodontal tissues over time has not been studied. In this study, we determined the azithromycin concentration in the gingiva and inflammatory connective tissue of the periodontal pocket in periodontal patients who had been administered azithromycin systemically. We also evaluated the clinical and microbiologic effects of azithromycin.

METHODS

Thirty-four patients with periodontitis were prescribed azithromycin 500 mg once daily for 3 days. During the 14-day study, clinical parameters (probing depth, gingival index, bleeding on probing, and gingival crevicular fluid level) were recorded, subgingival plaque was collected for bacteriologic examination, and the azithromycin concentration in the tissues lining the periodontal pocket was measured by agar diffusion bioassay.

RESULTS

Clinical parameters significantly improved after administration of azithromycin. The total number of cultivated bacteria also significantly decreased by day 4 but slightly increased after day 7. Sustained reduction in levels of six periodontopathic bacteria was not apparent until day 14. On day 7, the azithromycin concentration in the tissues lining the periodontal pockets was 50% of that on day 4, and on day 14 only 20%.

CONCLUSION

Azithromycin is detectable in inflamed periodontal tissues >or=14 days after systemic administration; it is associated with clinical and microbiologic improvement.

Effects of Full-Mouth Scaling and Root Planing in Conjunction With Systemically Administered Azithromycin

BACKGROUND

One-stage full-mouth disinfection (FMD), in which full-mouth scaling and root planing (SRP) is performed with adjunctive use of chlorhexidine, was introduced in 1995. There have been several reports on the effectiveness of this treatment protocol. However, FMD was reported to induce pyrexia frequently. We examined the effects of full-mouth SRP in conjunction with azithromycin administered orally before SRP to control the number of bacteria. The purpose of this study was to compare the effects of full-mouth SRP using azithromycin with conventional SRP.

METHODS

Thirty-four subjects (17 in the test group and 17 in the control group) with severe chronic periodontitis were selected. The subjects of the test group had azithromycin 3 days before full-mouth SRP. Clinical parameters (probing depth [PD], gingival index [GI], bleeding on probing [BOP], and gingival crevicular fluid [GCF]), total number of bacteria, and number of black pigment-producing rods (BPRs) were evaluated at baseline and 5, 13, and 25 weeks after baseline.

RESULTS

All clinical parameters improved in the test group more than in the control group. In the bacteriologic examination, the total number of bacteria did not change during the examination. In the test group, BPRs were not detected until 13 weeks. However, BPRs were detected in the control group by 13 weeks.

CONCLUSION

It was shown that full-mouth SRP using systemically administered azithromycin was a clinically and bacteriologically useful basic periodontal treatment for severe chronic periodontitis.

Clinical changes following four different periodontal therapies for the treatment of chronic periodontitis: 1-year results

OBJECTIVE

To compare clinical changes occurring in chronic periodontitis subjects receiving SRP alone or with systemically administered azithromycin, metronidazole or a sub-antimicrobial dose of doxycycline.

MATERIAL AND METHODS

92 chronic periodontitis subjects were randomly assigned to receive SRP alone (N=23) or combined with 500 mg azithromycin per day for 3 days (N=25), 250 mg metronidazole tid for 14 days (N=24) or 20 mg doxycycline bid for 3 months (N=20). Gingival redness, bleeding on probing, suppuration, pocket depth and attachment level were measured at baseline and 3, 6 and 12 months post therapy. The significance of changes in clinical parameters within groups over time was sought using the Friedman test and among groups using ANCOVA or the Kruskal Wallis test.

RESULTS

All groups showed clinical improvements at 12 months, with subjects receiving adjunctive agents showing a somewhat better response. Sites with initial pocket depth > 6 mm showed significantly greater pocket depth reduction and greater attachment gain in subjects receiving metronidazole or azithromycin than subjects in the other groups. Some subjects showed attachment loss at 12 months in each group ranging from 15% to 39% of subjects in the SDD and SRP only groups respectively.

CONCLUSION

This study, demonstrated that periodontal therapy provides clinical benefits and that antibiotics provide a clinical benefit over SRP alone, particularly at initially deeper periodontal pockets.

Antibacterial activity of a bacteriocin from Lactobacillus paracasei HL32 against Porphyromonas gingivalis

Porphyromonas gingivalis infections cause problems in periodontal diseases and in certain systemic diseases. There is evidence that Lactobacillus spp. can control populations of P. gingivalis, but there are few data on the effects of purified bacteriocins from Lactobacillus paracasei HL32 on P. gingivalis. The objective of this study was to examine the antibacterial activity of a bacteriocin from L. paracasei HL32 and to relate this activity to its composition. A bacteriocin was purified from culture supernatants of Lactobacillus spp. using a dialysis technique followed by gel-permeation chromatography. Composition of the bacteriocin was characterised by ninhydrin tests, ultraviolet spectrophotometry, thin-layer chromatography, sodium-dodecyl sulphate-polyacrylamide gel electrophoresis, electrospray ionisation mass spectrometry and amino acid analysis. The amino acid sequence from the N-terminal of the bacteriocin was determined. Antibacterial activity was examined by the cylinder plate method, microtitre assay and scanning electron microscopy as compared with standard antibiotics. The bacteriocin had a molecular weight of approximately 56kDa, was comprised of 68% carbohydrate and 32% protein, and showed maximum peak absorbance at 214 and 254nm. The bacteriocin was found to be effective against P. gingivalis; it caused swelling and pore formation on the cell envelope at a minimum bactericidal concentration of 0.14mM, and caused death within 2h. Metronidazole killed P. gingivalis but did not affect the envelope, whereas tetracycline affected P. gingivalis with cell deformation. In conclusion, the bacteriocin from L. paracasei HL32 had the ability to kill P. gingivalis, suggesting that it could be a promising alternative chemotherapeutic agent for P. gingivalis infections.

Effects of metronidazole plus amoxicillin as the only therapy on the microbiological and clinical parameters of untreated chronic periodontitis

AIM

To determine the effect of metronidazole plus amoxicillin (M+A) as the sole therapy, on the subgingival microbiota of chronic periodontitis.

MATERIAL AND METHODS

Twenty-two patients with untreated chronic periodontitis were randomly assigned to a group that received M+A for 7 days, or to a group receiving scaling and root planing (SRP) and two placebos. Clinical measurements including sites with plaque, bleeding on probing (BOP), probing depth (PD) and attachment level (AL) were made at baseline, 3, 6, 9 and 12 months. Subgingival plaque samples were taken from all teeth at baseline 3, 6, 9 and 12 months for the counts of 40 subgingival species using checkerboard DNA-DNA hybridization.

RESULTS

Mean PD was reduced from 2.80+/-0.45 at baseline to 1.95+/-0.05 at 12 months (P<0.001) and from 2.39+/-0.41 to 1.95+/-0.10 (P<0.001) in the M+A- and SRP-treated patients, respectively. Corresponding values for relative mean AL were 10.07+/-1.30-9.77+/-0.34 (P<0.001) and 9.94+/-0.28-9.77+/-0.26 (P<0.001). Percentage of sites exhibiting BOP were 40.6+/-18.3-14.0+/-1.4 (P<0.001), and 38.5+/-5.1-19.0+/-2.8 (P<0.001) in the M+A and SRP groups, respectively. Mean total DNA probe counts and counts of the majority of the 40 test species were significantly reduced over time in both groups, with no significant differences detected at any time point between groups. At 12 months many of the species were still present at significantly lowered levels compared with their baseline counts in both groups.

CONCLUSIONS

Changes in clinical and microbiological parameters were similar after receiving systemically administered M+A as the sole therapy or after receiving SRP only.

Clinical and microbiological effects of different antimicrobials on generalized aggressive periodontitis

AIM

To evaluate and compare the effects of adjunctive metronidazole plus amoxicillin, doxycycline and metronidazole on clinical and microbiological parameters in patients with generalized aggressive periodontitis.

MATERIAL AND METHODS

Forty-three patients participated in this randomized clinical trial divided into four groups. Six weeks after scaling and root planning (SRP), groups 1-3 received adjunctive metronidazole, plus amoxicillin, doxycycline and metronidazole respectively, and group 4 acted as controls. Clinical recordings concerning probing depth, probing attachment level and bleeding on probing were performed at baseline, 6 weeks after SRP and 6 months from baseline. Subgingival samples were analysed using the 'checkerboard' DNA-DNA hybridization for Porphyromonas gingivalis, Actinobacillus actinomycetemcomitans, Tannerella forsythia and Treponema denticola.

RESULTS

All treatments resulted in improvement of clinical parameters (ANOVA p > 0.05). Systemic administration of metronidazole plus amoxicillin or metronidazole resulted in statistically significant greater reduction of the proportion of sites > 6 mm than SRP (z-test, p < 0.05). These antimicrobials yielded a significant effect on levels of important periodontal pathogens for 6 months.

CONCLUSION

Adjunctive metronidazole plus amoxicillin or metronidazole alone (when A.actinomycetemcomitans is not involved) is effective in deep pockets of aggressive periodontitis patients.

Local Drug Delivery in the Treatment of Periodontal Diseases: Assessing the Clinical Significance of the Results

BACKGROUND

Local drug delivery can be used in the management of periodontal patients. However, statistically significant responses to therapy recorded in clinical trials may not be clinically significant.

METHODS

Controlled clinical trials were selected that assessed the capability of local drug delivery to improve periodontal health.

RESULTS

Several local drug delivery systems employed as monotherapies improved periodontal health and provided results that were not statistically significantly different than attained with scaling and root planing (SRP) alone. In contrast, many local drug delivery devices when used as adjuncts to SRP provided a statistically significant enhancement of parameters commonly used to monitor periodontal status. However, mean improvements with respect to probing depth reduction or gain of clinical attachment were often limited to tenths of millimeters. Several devices also achieved specific criteria that can be used to identify clinically significant findings (e.g., number of sites with probing depth reduction >or=2 mm). However, there are conflicting data with respect to the ability of local drug delivery to enhance results of SRP at deep probing sites, and there is limited information relative to its capability to inhibit disease progression or enhance osseous repair in infrabony defects.

CONCLUSION

The decision to use local drug delivery during active treatment or maintenance should be based upon clinical findings, responses to therapy recorded in the literature, desired clinical outcomes, and the patient's dental and medical history.

Oral Health Impacts on Daily Living Related to Four Different Treatment Protocols for Chronic Periodontitis

BACKGROUND

The aims of this study were to evaluate the oral health impacts perceived by patients submitted to different treatments of chronic periodontitis and their association with clinical parameters.

METHODS

Sixty patients were assigned to one of the following therapeutic groups: control, treated with full-mouth scaling and root planing (SRP); test 1, treated with SRP and 400 mg systemically administered metronidazole (MET) three times per day for 10 days; test 2, treated with SRP and professional supragingival plaque removal (PP) every week for 3 months; and test 3, treated with SRP and MET plus PP. Clinical periodontal measurements and data regarding patients' oral health impacts (perceived impacts on bleeding gums, gingival recession, sensitivity to cold, packing foods, aesthetics, bad breath, and tooth mobility) were collected at baseline and 3 months after therapy.

RESULTS

All groups presented significant improvement in oral health perceived impacts. There was no statistically significant difference in the improvement of oral health impacts among groups subjected to different treatments. The clinical data of percentage of deep probing depth, deep clinical attachment level, and bleeding on probing were found to be correlated significantly with oral health impacts.

CONCLUSIONS

Periodontal treatment leads to a significant reduction of self-perceived impacts regardless of the non-surgical treatment protocol employed. Most of the clinical data were associated with oral health impacts.

Periodontal dressing (VocopacR) influences outcomes in a two-step treatment procedure

OBJECTIVES

It is not clear if periodontal dressing influences the long-term results in a non-surgical treatment procedure.

MATERIAL AND METHODS

The periodontal parameters (pre-baseline) of 36 patients with aggressive periodontitis were obtained before the patients were treated initially (1st step) by a dental hygienist, who completely removed the supra- and subgingival concrements. Baseline parameters were raised 3 weeks after the 1st step, before the 2nd therapy step was conducted. It consisted of a non-surgical procedure, which comprised a closed full-mouth manual root curettage (root planing), immediate systemic application of metronidazole, and the placement of a periodontal dressing (Vocopac, Voco). The patients were randomized to two test groups having their periodontal packs removed after 3-4 days (group 1, n=12) and 7-8 days (group 2, n=12), respectively and a control group (n=12) without periodontal dressing. Clinical parameters were raised again after 6 and 24 months.

RESULTS

Six and 24 months later, changes in probing pocket depth (PPD) and probing attachment level (PAL) were observed in all three groups compared with baseline, but the difference was significant in group 2 only. In addition, group 2 showed a greater reduction in mean PPD and also a significantly greater gain of attachment in comparison with the controls.

CONCLUSION

Wound dressing has a positive effect on clinical long-term results using a two-step non-surgical procedure. Moreover, removing the dressing after 7-8 days leads to clearly better results than removing it earlier.

Scaling and root planing, systemic metronidazole and professional plaque removal in the treatment of chronic periodontitis in a Brazilian population II - microbiological results

OBJECTIVE

The current investigation evaluated changes in levels and proportions of 39 bacterial species in subgingival plaque samples after scaling and root planing (SRP) alone or in combination with systemic metronidazole and/or professional cleaning in subjects with chronic periodontitis.

METHODS

Forty-four adult subjects (mean age 45+/-6 years) with periodontitis were randomly assigned in four treatment groups, a control (C, n=10) that received SRP and placebo and three test groups treated as follows: T1 (n=12): SRP and metronidazole (M, 400 mg tid) for 10 days; T2 (n=12): SRP, weekly professional supragingival plaque removal for 3 months (PC) and placebo; and T3 (n=10): SRP, M and PC. Subgingival plaque samples were taken from seven sites per subject at baseline and 90 days post-therapy. Counts of 39 subgingival species were determined using checkerboard DNA-DNA hybridization. Significance of differences over time was determined using the Wilcoxon signed ranks test and among groups using ancova.

RESULTS

The mean counts of the majority of the species were reduced post-therapy in the 4 treatment groups. Counts (x 10(5)+/-SEM) of Porphyromonas gingivalis, Tannerella forsythensis and Treponema denticola were significantly reduced in groups T2 and T3. Levels of beneficial species, such as some Actinomyces species, Veillonella parvula, Streptococcus sanguis, Streptococcus oralis and Streptococcus gordonii were minimally affected in levels when the combined therapy was applied (T3). Mean proportions of red complex species decreased from 18.4% at baseline to 3% at 90 days post-therapy in group T3 (p<0.01), from 25.8% to 2.3% in group T2 (p<0.01), from 17.7% to 5.6% in group T1 (p<0.05) and from 19.4% to 8.8% in group C (NS). Proportions of the suspected periodontal pathogens from the orange complex were also markedly reduced in groups T2 and T3.

CONCLUSIONS

All treatments reduced counts and proportions of red complex species. Adjunctive therapy appeared to have a greater effect and also affected members of the orange complex.

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.

Scaling and root planing, systemic metronidazole and professional plaque removal in the treatment of chronic periodontitis in a Brazilian population. I. Clinical results

OBJECTIVE

The current investigation evaluated the clinical effects of scaling and root planing (SRP) alone or in combination with systemic metronidazole and/or repeated professional removal of supragingival plaque in subjects with chronic periodontitis.

METHODS

Fourty-four adult subjects (mean age: 45+/-6 years) with periodontitis were randomly assigned to four treatment groups; a control (C, n=10) that received SRP and placebo and three test groups treated as follows: Test 1 (T1) (n=12) received SRP and metronidazole (400 mg t.i.d., M) for 10 days; Test 2 (T2) (n=12) received SRP, weekly professional supragingival plaque removal for three months (professional cleaning (PC)) and placebo; and Test 3 (T3) (n=10) received SRP, M and PC. Pocket depth (PD), attachment level (AL), bleeding on probing (BOP) and presence of visible plaque and suppuration were measured at six sites per tooth at baseline and at 90 days post-therapy. Significance of differences over time was determined using the Wilcoxon test, and among groups using ancova.

RESULTS

A reduction in full-mouth mean clinical parameters was observed at 90 days after all therapies. Sites with baseline PD<4 mm showed an increase in mean PD in the control group and in mean AL in all treatment groups. Sites with baseline PD of 4-6 mm in subjects who received PC as part of therapy (T2, T3) showed a marked reduction in PD, AL and in the % of sites with BOP. Subjects who received metronidazole (T1 and T3) showed the best clinical response at sites with an initial PD of >6 mm. The major clinical benefit occurred when the combination of SRP, M and PC was used. Group T3 showed the least attachment loss in initially shallow pockets. This group also exhibited the greatest reduction in the % of sites with BOP and suppuration as well as in mean PD and AL at sites with baseline PD>4 mm.

CONCLUSION

The data suggest a significant clinical benefit in combining SRP, systemic metronidazole and weekly professional supragingival plaque removal for the treatment of chronic periodontitis.

Systemic anti-infective periodontal therapy. A systematic review

BACKGROUND

Periodontal diseases are infections and thus systemically administered antibiotics are often employed as adjuncts for their control. There are conflicting reports as to whether these agents provide a therapeutic benefit.

RATIONALE

The purpose of this systematic review is to determine whether systemically administered antibiotics improve a primary clinical outcome measure, periodontal attachment level change.

FOCUSED QUESTION

In patients with periodontitis, what is the effect of systemically administered antibiotics as compared to controls on clinical measures of attachment level?

SEARCH PROTOCOL

The Pub/Med database was searched from 1966 to May 2002. Searches were limited to human studies published in English. Hand searches were performed on the Journal of Clinical Periodontology, Journal of Periodontology, and Journal of Periodontal Research. References in relevant papers and review articles were also examined.

SELECTION CRITERIA

INCLUSION CRITERIA

Trials were selected if they met the following criteria: randomized controlled clinical trials, quasi-experimental studies, and cohort studies of > 1 month duration with a comparison group; subjects with aggressive, chronic, or recurrent periodontitis and periodontal abscess; use of a single or a combination of systemically administered antibiotics(s) versus non-antibiotic therapy; and a primary outcome of mean attachment level change (AL).

EXCLUSION CRITERIA

Studies involving the use of low-dose doxycycline, combinations of locally plus systemic antibiotics, or where the control group included a systemically administered antibiotic were excluded.

DATA COLLECTION AND ANALYSIS

A mean difference in AL between groups was available for all papers used in the meta-analysis. A standard deviation (SD) for the difference was used if provided or calculated from the SD or standard error of the mean (SEM) when provided for single measurements. Data were subset by antibiotic employed, type of adjunctive therapy, and disease type. Results were assessed with both fixed-effects and random-effects models.

MAIN RESULTS

1. Twenty-nine studies, 26 RCTs and 3 quasi-experimental (36 comparisons), met the entry criteria. Total study population, both control and test groups, was estimated at over 1,200. 2. Twenty-two studies (27 comparisons) were used in the meta-analysis, evaluating if the antibiotics provided a consistent benefit in mean AL change for different patient populations, for different therapies, and for different antibiotics. 3. For the majority of the comparisons, systemically administered antibiotics exhibited a more positive attachment level change than the control group in the study. The combined results were statistically significant (P < 0.001). 4. The systemic antibiotics were uniformly beneficial in providing an improvement in AL when used as adjuncts to scaling and root planing (SRP) and were consistently beneficial, although of borderline significance, when used as adjuncts to SRP plus surgery or as a stand alone therapy. 5. When examining the effects of individual or combinations of antibiotics, it was found that there were statistically significant improvements in AL for tetracycline, metronidazole, and an effect of borderline statistical significance for the combination of amoxicillin plus metronidazole. 6. Improvements in mean AL were consistent for both chronic and aggressive periodontitis subjects, although the aggressive periodontitis patients benefited more from the antibiotics.

REVIEWERS' CONCLUSIONS

1. The use of systemically administered adjunctive antibiotics with and without SRP and/or surgery appeared to provide a greater clinical improvement in AL than therapies not employing these agents. 2. The data supported similar effect sizes for the majority of the antibiotics; therefore, the selection for an individual patient has to be made based on other factors. 3. Due to a lack of sufficient sample size for many of the antibiotics tested, it is difficult to provide guidance as to the more effective ones.

A systematic review on the effect of systemic antimicrobials as an adjunct to scaling and root planing in periodontitis patients

BACKGROUND

Scaling and root planing (SRP) are the bases of non-surgical therapy in the treatment of periodontitis. However, results from this therapy are often unpredictable and dependable from many different factors.

OBJECTIVES

The aim of this systematic review was to evaluate the effectiveness of the adjunctive use of systemic antimicrobials with scaling and root planing (SRP) vs. SRP alone in the treatment of chronic (CP) or aggressive periodontitis (AgP).

SEARCH STRATEGY

Use of computerized databases, namely MEDLINE, the Cochrane Oral Health Group Specialty Trials Register and EMBASE; reference lists from relevant articles were hand-searched; and a hand-search of selected journals until April 2001.

SELECTION CRITERIA

Studies were selected if they were designed as controlled clinical trials in which systemically healthy patients with either AgP or CP were treated with SRP plus systemic antimicrobials in comparison with SRP alone or with placebo, for a minimum of 6 months. Main outcome measures were clinical attachment level (CAL) change and probing pocket depth (PPD) change.

DATA COLLECTION AND ANALYSIS

Two reviewers extracted independently information regarding quality and study characteristics, in duplicate. Kappa scores determined their agreement. Main results were collected and grouped by drug, disease and PPD category. For the quantitative data synthesis, the data was pooled (when mean differences and standard errors were available), and either a Fixed Effects or Random Effects meta-analysis was used for the analysis.

RESULTS

After an initial selection, 158 papers were identified by the manual and electronic searches; 25 papers were eligible for inclusion. Their quality assessment showed that randomization and allocation concealment methods were seldom reported and blindness was usually not defined clearly. In general, selected studies showed high variability and lack of relevant information for an adequate assessment. Overall, SRP plus systemic antimicrobial groups demonstrated better results in CAL and PPD change than SRP alone or with placebo groups. Only limited meta-analyses could be performed, due to the difficulties in pooling the studies and the lack of appropriate data. This analysis showed a statistically significant additional benefit for spiramycin (PPD change) and amoxicillin/metronidazole (CAL change) in deep pockets.

CONCLUSION

Systemic antimicrobials in conjunction with SRP, can offer an additional benefit over SRP alone in the treatment of periodontitis, in terms of CAL and PPD change, and reduced risk of additional CAL loss. However, differences in study methodology and lack of data precluded an adequate and complete pooling of data for a more comprehensive analyses. It was difficult to establish definitive conclusions, although patients with deep pockets, progressive or 'active' disease, or specific microbiological profile, can benefit more from this adjunctive therapy.

Meta-analysis of the effect of scaling and root planing, surgical treatment and antibiotic therapies on periodontal probing depth and attachment loss

OBJECTIVE

This paper reports a meta-analysis of studies that have investigated the effect of scaling and root planing on periodontal probing depth and attachment loss.

MATERIAL AND METHODS

The criteria used for inclusion of studies were as follows: root planing and scaling alone was one of the primary treatment arms; patients or quadrants of each patient were randomly assigned to study groups; 80% of patients enrolled were included in first year follow-up examinations; periodontal probing depth and attachment loss were reported in mm; the sample size of each study and substudy was reported. Sample size was used to weight the relative contribution of each study since standard errors were not reported by many studies and sample size is highly correlated with standard error and therefore statistically able to explain a substantial portion of the standard error on studies that use similar measures.

RESULTS

The meta-analysis results show that periodontal probing depth and gain of attachment level do not improve significantly following root planing and scaling for patients with shallow initial periodontal probing depths. However, there was about a 1-mm reduction for medium initial periodontal probing depths and a 2-mm reduction for deep initial periodontal probing depths. Similarly, there was about a 0.50-mm gain in attachment for medium initial periodontal probing depth measurements and slightly more than a l-mm gain in attachment for deep initial periodontal probing depth measurements. Surgical therapy for patients with deep initial probing depths showed better results than scaling and root planing in reducing probing depths. When patients were followed up over 3 years or more, these differences were reduced to less than 0.4 mm. Antibiotic therapy showed similar results to scaling and root planing. However, a consistent improvement in periodontal probing depth and gain of attachment is demonstrated when local antibiotic therapy is combined with root planing and scaling.

Rationale for use of antibiotics in periodontics

The purpose of this review is to provide the clinician with some practical rationale for the selection and use of antibiotics in the treatment of destructive periodontal diseases. We have attempted to integrate approximately 20 years of periodontal literature describing antibiotic therapy with personal experience and 21st century ideas. This article addresses antibiotic use during treatment of aggressive periodontitis with emphasis on juvenile disease and adult refractory diseases. The literature review revealed few large, controlled studies that compared efficacy of adjunctive antibiotic use to mechanical therapy alone. Even fewer studies evaluated the efficacy of one antibiotic relative to another. However, based on the evidence available, certain conclusions were drawn. Adjunctive use of an antibiotic along with mechanical debridement is recommended for the treatment of Actinobacillus actinomycetemcomitans-associated periodontitis as an acceptable therapeutic regimen. Due to the emergence of tetracycline-resistant A. actinomycetemcomitans, the combination of metronidazole and amoxicillin may be preferable. In aggressive refractory periodontitis, compelling evidence exists that the use of an appropriate adjunctive antibiotic frequently gives a more favorable clinical response than mechanical therapy alone. Unfortunately, the selection of antibiotic is not as clear and is probably case-dependent. Positive responses have been reported with amoxicillin/clavulanic acid, clindamycin, metronidazole, and the combination therapy metronidazole plus amoxicillin. The introduction of local delivery antibiotics specifically for the treatment of periodontitis offers a novel concept for the treatment of localized disease. The latter, in particular, may prove useful in the treatment of recurrent disease activity or where only a few individual sites are involved.