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

The use of systemic antibiotics in the treatment of refractory periodontitis: A systematic review

BACKGROUND

The goal in treating refractory periodontitis (RP) is to arrest or slow disease progression, which usually has included the use of systemic antibiotics adjunct to conventional mechanical debridement. The aim of this systematic review was to evaluate the evidence that the association of systemic antibiotics with conventional mechanical debridement increases the efficacy of periodontal therapy in the treatment of RP.

TYPES OF STUDIES REVIEWED

The authors searched for studies in PubMed MEDLINE, Cochrane Central Register of Controlled Trials, Thomson Reuters Web of Science, Scopus, Latin American and Caribbean Center on Health Sciences Information, and Scientific Electronic Library Online electronic databases by using selected key words from the earliest records up through October 31, 2014. Only clinical intervention studies in which investigators compared the treatment of participants with RP with either mechanical debridement alone or associated with systemic antibiotics were eligible for selection. Two authors independently assessed the risk of bias of each selected study.

RESULTS

The authors identified 13 articles and included 6 of them. Investigators in all studies reported greater reductions in probing depth or in loss of clinical attachment level after adjunct systemic antibiotic therapy when compared with mechanical debridement alone. Antibiotics tested included metronidazole, clindamycin, tetracycline hydrochloride, amoxicillin, and amoxicillin and potassium clavulanate. Five studies presented a high risk of bias, and 1 study presented an unclear risk.

CONCLUSIONS AND PRACTICAL IMPLICATIONS

The overall quality of the evidence does not allow the conclusion that adjunct systemic antibiotics are of additional benefit to conventional mechanical debridement alone.

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.

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.

Biofilm Lysine Decarboxylase, a New Therapeutic Target for Periodontal Inflammation

BACKGROUND

Lysine, a nutritionally essential amino acid, enters the oral cavity in gingival crevicular fluid (GCF). During oral hygiene restriction (OHR), lysine decarboxylase (LDC) in dento-gingival biofilms converts lysine to cadaverine. Lysine depletion impairs the dental epithelial barrier to bacterial proinflammatory products. Antibodies to LDC from Eikenella corrodens (Ecor-LDC) inhibit LDC activity and retard gingival inflammation in beagle dogs. Whether E. corrodens is the major source of LDC in dental biofilms and whether the lysine analog tranexamic acid (TA) inhibits LDC activity, biofilm accumulation, and GCF exudation in a human gingivitis model were examined.

METHODS

Antibodies raised in goats to LDC-rich extracts from E. corrodens cell surfaces were used to inhibit Ecor-LDC and detect it in biofilm extracts using Western blots. Ecor-LDC activity was measured at pH 4.0 to 11.0 and its TA dissociation constant (Ki) at pH 7.0. Young adults used a 5% or 10% TA mouthwash three times daily during OHR for 1 week.

RESULTS

Ecor-LDC antibodies and TA inhibited biofilm LDC. Ki of TA for Ecor-LDC was 940 μM. TA reduced plaque index (PI) by downshifting the PI correlation with biofilm lysine content after OHR without TA. GCF was correspondingly suppressed. However, greater TA retention in saliva partially relieved GCF suppression but not biofilm lysine depletion.

CONCLUSIONS

TA slightly inhibits LDC but strongly reduces biofilm by inhibiting bacterial lysine uptake. Unfortunately, TA may impair dental epithelial attachments by also inhibiting lysine transporter uptake. Ecor-LDC inhibitors other than lysine analogs may maintain sufficient lysine levels and attachment integrity to prevent periodontal inflammation.

Development and characterization of novel ZnO-loaded electrospun membranes for periodontal regeneration

OBJECTIVES

This study reports on the synthesis, materials characterization, antimicrobial capacity, and cytocompatibility of novel ZnO-loaded membranes for guided tissue/bone regeneration (GTR/GBR).

METHODS

Poly(ɛ-caprolactone) (PCL) and PCL/gelatin (PCL/GEL) were dissolved in hexafluoropropanol and loaded with ZnO at distinct concentrations: 0 (control), 5, 15, and 30wt.%. Electrospinning was performed using optimized parameters and the fibers were characterized via scanning and transmission electron microscopies (SEM/TEM), energy dispersive X-ray spectroscopy (EDS), Fourier transform infrared spectroscopy (FTIR), contact angle (CA), mechanical testing, antimicrobial activity against periodontopathogens, and cytotoxicity test using human dental pulp stem cells (hDPSCs). Data were analyzed using ANOVA and Tukey (α=5%).

RESULTS

ZnO nanoparticles were successfully incorporated into the overall submicron fibers, which showed fairly good morphology and microstructure. Upon ZnO nanoparticles' incorporation, the PCL and PCL/GEL fibers became thicker and thinner, respectively. All GEL-containing membranes showed lower CA than the PCL-based membranes, which were highly hydrophobic. Overall, the mechanical properties of the membranes were reduced upon ZnO incorporation, except for PCL-based membranes containing ZnO at the 30wt.% concentration. The presence of GEL enhanced the stretching ability of membranes under wet conditions. All ZnO-containing membranes displayed antibacterial activity against the bacteria tested, which was generally more pronounced with increased ZnO content. All membranes synthesized in this study demonstrated satisfactory cytocompatibility, although the presence of 30wt.% ZnO led to decreased viability.

SIGNIFICANCE

Collectively, this study suggests that PCL- and PCL/GEL-based membranes containing a low content of ZnO nanoparticles can potentially function as a biologically safe antimicrobial GTR/GBR membrane.

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.

Comparison of an essential-oil-based oral rinse and chlorhexidine as adjuncts to scaling and root planing in the treatment of periodontal inflammation

OBJECTIVE

The aim of the present short-term follow-up study was to compare the effects of an essential oil (EO)-based oral rinse and chlorhexidine as adjuncts to scaling and root planing (SRP) in the treatment of periodontal inflammation.

METHODS

In Group-1, SRP was performed and participants were instructed to rinse with EO-based oral rinse; in Group-2, SRP was performed and participants were instructed to rinse with chlorhexidine; and in Group-3, SRP was performed and participants were instructed to rinse with water. Periodontal parameters (plaque index [PI], bleeding-on-probing [BOP], and probing pocket depth [PPD] ≥ 4 mm) were assessed at baseline and after 7 and 30 days.

RESULTS

In all groups, periodontal parameters (PI, BOP, and PPD ≥ 4 mm) were comparable at baseline. In Groups-1 and -2, there was a significant reduction in PI (P < 0.01), BOP (P < 0.01), and PD ≥ 4 mm after 7 days and 30 days of follow-up than baseline. In Group-3, there was a significant reduction in PI (P < 0.01) and BOP (P < 0.01) after 7 days of follow-up compared to baseline. There was no difference in periodontal parameters after 7 days and 30 days of follow-up in Groups-1 and -2.

CONCLUSION

EO-based oral rinses and chlorhexidine digluconate (CHX) are acceptable adjuncts to SRP in the treatment of periodontal inflammation.

Changes in antimicrobial susceptibility profile and prevalence of quinolone low-sensitive strains in subgingival plaque from acute periodontal lesions after systemic administration of sitafloxacin

This study aimed to assess changes in antimicrobial susceptibilities of subgingival bacteria in acute periodontal lesions following systemic administration of a new-generation fluoroquinolone, sitafloxacin and to monitor the occurrence and fate of quinolone low-sensitive strains. Patients with acute phase of chronic periodontitis were subjected to microbiological assessment of their subgingival plaque samples at baseline (A1). Sitafloxacin was then administered systemically (100 mg/day for 5 days). The microbiological examinations were repeated one week after administration (A2). Susceptibilities of clinical isolates from acute sites to various antimicrobials were determined using broth and agar dilution methods. At A2, subgingival bacteria with low sensitivity to levofloxacin were identified in four patients, and they were subjected to a follow-up microbiological examination at on the average 12 months after sitafloxacin administration (A3). The patients received initial and supportive periodontal therapy during the period A2 to A3. From the examined subgingival sites, 8 and 19 clinical isolates were obtained at A2 and A3, respectively. Some Streptococcus strains isolated at A2 were found to be resistant to levofloxacin (MIC 16-64 μg/ml), azithromycin (MIC 2->128 μg/ml) or clarithromycin (MIC 1->32 μg/ml). At A3, isolated streptococci were highly susceptible to levofloxacin (MIC 0.5-2 μg/ml), while those resistant to azithromycin or clarithromycin were still isolated. It is suggested that the presence of the quinolone low-sensitive strains in initially acute lesions after sitafloxacin administration was transient, and they do not persist in the subgingival milieu during the periodontal therapy.

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.

Variation on a theme; an overview of the Tn916/Tn1545 family of mobile genetic elements in the oral and nasopharyngeal streptococci

The oral and nasopharyngeal streptococci are a major part of the normal microbiota in humans. Most human associated streptococci are considered commensals, however, a small number of them are pathogenic, causing a wide range of diseases including oral infections such as dental caries and periodontitis and diseases at other body sites including sinusitis and endocarditis, and in the case of Streptococcus pneumoniae, meningitis. Both phenotypic and sequence based studies have shown that the human associated streptococci from the mouth and nasopharynx harbor a large number of antibiotic resistance genes and these are often located on mobile genetic elements (MGEs) known as conjugative transposons or integrative and conjugative elements of the Tn916/Tn1545 family. These MGEs are responsible for the spread of the resistance genes between streptococci and also between streptococci and other bacteria. In this review we describe the resistances conferred by, and the genetic variations between the many different Tn916-like elements found in recent studies of oral and nasopharyngeal streptococci and show that Tn916-like elements are important mediators of antibiotic resistance genes within this genus. We will also discuss the role of the oral environment and how this is conducive to the transfer of these elements and discuss the contribution of both transformation and conjugation on the transfer and evolution of these elements in different streptococci.