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

Antibiotic resistance in the microbiota of periodontitis patients: an update of current findings

Systemic antibiotics are an effective adjunct in the treatment of periodontitis, but their judicious use is necessary as antimicrobial resistance is a growing global concern. This review aims to explore the current understanding and insight related to antibiotic resistance in the subgingival microbiota of periodontitis patients. A search of MEDLINE (PubMed) was carried out from 1 January 2012 to 25 November 2021 for studies related to antibiotic resistance in periodontitis patients. Of the 90 articles identified, 12 studies were selected for inclusion. A significant incidence of antibiotic resistant isolates was reported for Porphyromonas gingivalis, Prevotella intermedia, Prevotella denticola, Prevotella melaninogenica, Fusobacterium nucleatum, Tanerella forsythia, Aggretibacter actinomycetemcomitans, Streptococcus constellatus, Streptococcus intermedius, and Parvimonas micra, but resistance to specific antibiotics did not reach above 10% of isolates in most studies except for amoxicillin resistance in Aggretibacter actinomycetemcomitans. The highest frequency of resistance across all bacterial species was for amoxicillin, clindamycin, and metronidazole. However, resistance patterns were widely variable across geographical locations, and the high heterogeneity between antibiotic-resistant isolates across studies precludes any clinical recommendations from this study. Although antibiotic resistance has yet to reach critical levels in periodontitis patients, an emphasis on antibiotic stewardship interventions such as point-of-care diagnostics and education for key stakeholders is needed to curb a growing problem.

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.

A questionnaire-based crossover study on the association of microbiological testing with prescription of systemic antibiotics following initial periodontal therapy

AIM

(1) To assess prescription of systemic antibiotics following initial periodontal therapy with and without the availability of microbiological information; (2) To identify factors associated with prescription of systemic antibiotics following initial periodontal therapy.

MATERIALS AND METHODS

Twenty-four clinicians were invited to complete a questionnaire on 20 patient records with respect to periodontal treatment planning, once with microbiological information available and once without. Randomization determined when the microbiological information was provided, and a 3-month washout period was respected between scoring sessions. Regression analysis was performed to identify factors associated with prescription of systemic antibiotics.

RESULTS

Twenty-one clinicians completed both scoring sessions. Clinicians prescribed systemic antibiotics in on average 56% (95% Confidence Interval (CI) [0.51; 0.61]) of the cases having microbiological information, and in 52% (95% CI [0.47; 0.57]) of the same cases not having that information (p = 0.094). The odds for prescribing systemic antibiotics were 3.34 (95% CI [2.06; 5.42]) times higher when the clinician had at least 3 years of experience, 2.55 (95% CI [1.40; 4.66]) times higher for patients diagnosed with periodontitis stage IV when compared to stage III, 1.08 (95% CI [1.04; 1.11]) times higher for younger patients, 2.78 times (95% CI [1.37; 5.56]) times higher for non-smokers and 2.22 (95% CI [1.27; 3.85]) times higher when less than three teeth would require extraction. No significant associations with the prescription of systemic antibiotics were found for detection of A.actinomycetemcomitans (p = 0.287), grade of periodontitis (p = 0.499) and gender of the patient (p = 0.067).

CONCLUSIONS

Based on a limited number of cases and clinicians, several patient and clinician related factors were associated with prescription of systemic antibiotics following initial periodontal therapy. However, microbiological testing was not.

Antibiotic Therapy in Dentistry

Dental caries, pulpal necrosis, trauma, and periodontal diseases can result in dental infections which could have severe consequences that affect both soft and hard tissues of the oral cavity. Dental infections commonly present with symptoms of pain, fever, and swelling. Surgical and endodontic treatments are the early management of infected teeth, followed by antibiotic therapy. Some alternative methods also exist for treating infection such as low-level laser therapy and photodynamic therapy. Antibiotics are generally used in dental procedures to treat odontogenic infections, nonodontogenic infections, local infection, focal infection, and prophylaxis. Antibiotic prophylaxis is prescribed for patients with immunosuppressed conditions, infective endocarditis, metabolic disorders, and patients with prosthetic joints. To reduce the complications of unnecessary antibiotic prescriptions especially bacterial resistance, comprehensive guidelines should be established. It has been noted that only about 12% of dentists adequately and correctly prescribe antibiotics, which shows the importance of comprehensive guidelines. Antibiotics prescription may result in some adverse effects such as hypersensitivity reactions and dermatological and allergic disorders. Furthermore, unnecessary prescription of antibiotics could result in several serious sequelae, for example, bacterial resistance, gastric and hematological problems, and diversion of bacterial microbiota. The present review attempts to summarize the indications of antibiotic therapy in dentistry and discuss the common types of antibiotics that are routinely used in dental practice based on pharmacologic classes. Moreover, types of antibiotics that are considered safe during pregnancy and childhood are also reviewed.

Disease severity, debridement approach and timing of drug modify outcomes of adjunctive azithromycin in non-surgical management of chronic periodontitis: a multivariate meta-analysis

Background

Past meta-analyses have shown adjunctive systemic Azithromycin (AZI) to provide minor clinical benefits in scaling and root surface debridement (S/RSD). However, these have not considered the covariance of key outcome parameters; probing pocket depth (PPD) and Clinical Attachment Level (CAL) or systematically examined some potential sources of heterogeneity.

Aim

To jointly synthesize 6-month outcomes of systemic AZI as adjunctive to S/RSD in chronic periodontitis and investigate 3 potential sources of heterogeneity.

Methods

Four databases were searched for suitable randomized controlled clinical trials (RCTs). Standardized mean differences (SMD) in PPD and CAL between AZI + S/RSD and S/RSD alone, at 6-month follow-up were computed. Within-study covariances of PPD and CAL were derived from reported multiple time-point data. A multivariate meta-analysis with random effects jointly modelled PPD and CAL, factoring in their covariance. This model included 3 moderators with interaction effects; timing of AZI initiation (pre-therapy/post-therapy), type of S/RSD [full-mouth debridement (FMD)/partial-mouth debridement (PMD)], and baseline study-level mean values of PPD/CAL.

Results

Among 276 abstracts, 11 observations from 9 RCTs qualified for meta-analysis. Within-study correlation-coefficients of PPD with CAL significantly increased with increasing study-level baseline mean values (Spearman’s r = 0.79, p < 0.01). The full multivariate meta-analysis model showed significant effects for the 3 moderators (Q statistic = 150.03, p < 0.01), retained significant residual heterogeneity (Q statistic = 88.50, p < 0.01) but outperformed (Likelihood- ratio statistic = 102.95, p < 0.01,) a null-model with no moderators (Q statistic = 201.5, p < 0.01). A significant effect was seen only on the SMD for PPD (estimate = 1.16 mm, 95% CI: 0.27 mm–2.07 mm mm, p = 0.01) but not CAL (estimate = 0.17 mm, 95% CI: -0.92 mm-1.26 mm, p = 0.76). SMD in PPD positively interacted with study baseline value (estimate = 0.11, 95% CI: 0.08–0.15, p < 0.01). Significant negative interactions of SMD in PPD with PMD (estimate = − 1.25 mm, 95% CI: -1.73 mm- -0.78 mm, p < 0.01) and pre-therapy drug initiation (estimate = − 1.18 mm, 95% CI: -1.48 mm--0.87 mm, p < 0.01) were evident.

Conclusion

Joint synthesis of PPD and CAL showed, at 6-months, AZI + S/RSD provided a benefit over S/RSD alone for PPD alone when correlation with CAL was accounted for. Deeper study-level baseline PPD, FMD type of S/RSD, and post-therapy drug initiation associated with greater PPD reduction.

Electronic supplementary material

The online version of this article (10.1186/s12903-019-0754-0) contains supplementary material, which is available to authorized users.

Azithromycin Promotes the Osteogenic Differentiation of Human Periodontal Ligament Stem Cells after Stimulation with TNF-α

Background and Objective

This study investigated the effects and underlying mechanisms of azithromycin (AZM) treatment on the osteogenic differentiation of human periodontal ligament stem cells (PDLSCs) after their stimulation with TNF-α in vitro. Methods. PDLSCs were isolated from periodontal ligaments from extracted teeth, and MTS assay was used to evaluate whether AZM and TNF-α had toxic effects on PDLSCs viability and proliferation. After stimulating PDLSCs with TNF-α and AZM, we analyzed alkaline phosphatase staining, alkaline phosphatase activity, and alizarin red staining to detect osteogenic differentiation. Real-time quantitative polymerase chain reaction (RT-qPCR) analysis was performed to detect the mRNA expression of osteogenic-related genes, including RUNX2, OCN, and BSP. Western blotting was used to measure the NF-κB signaling pathway proteins p65, phosphorylated p65, IκB-α, phosphorylated IκB-α, and β-catenin as well as the apoptosis-related proteins caspase-8 and caspase-3. Annexin V assay was used to detect PDLSCs apoptosis.

Results

TNF-α stimulation of PDLSCs decreased alkaline phosphatase and alizarin red staining, alkaline phosphatase activity, and mRNA expression of RUNX2, OCN, and BSP in osteogenic-conditioned medium. AZM enhanced the osteogenic differentiation of PDLSCs that were stimulated with TNF-α. Western blot analysis showed that β-catenin, phosphorated p65, and phosphorylated IκB-α protein expression decreased in PDLSCs treated with AZM. In addition, pretreatment of PDLSCs with AZM (10 μg/ml, 20 μg/ml) prevented TNF-α-induced apoptosis by decreasing caspase-8 and caspase-3 expression.

Conclusions

Our results showed that AZM promotes PDLSCs osteogenic differentiation in an inflammatory microenvironment by inhibiting the WNT and NF-κB signaling pathways and by suppressing TNF-α-induced apoptosis. This suggests that AZM has potential as a clinical therapeutic for periodontitis.

Administration of systemic antibiotics during non-surgical periodontal therapy-a consensus report

AIM

The aim of this meta-review was to evaluate whether there is a meaningful clinical benefit regarding the use of systemic adjunctive antibiotics in the treatment of patients with periodontitis. Additionally, a consensus regarding possible recommendations for future administration of antibiotics should be reached.

METHODS

A structured literature search was performed by two independent investigators focusing on systematic reviews (SR) covering adjunctive systemic antibiosis during non-surgical periodontal therapy. Additionally, recent randomized clinical trials (RCT, July 2015 to July 2017) were searched systematically to update the latest SR. Results were summarized and discussed in a plenary to reach a consensus.

RESULTS

Mostly, systematic reviews and RCTs showed a significant positive effect of adjunctive systematic antibiosis compared to controls. These positive effects gain clinical relevance in patients with severe periodontal disease aged 55 years and younger.

CONCLUSION

Systemic antibiotics as an adjunct to non-surgical periodontal therapy should be sensibly administered and restrictively used. Only certain groups of periodontitis patients show a significant and clinically relevant benefit after intake of systemic antibiosis during periodontal therapy.

CLINICAL RELEVANCE

Avoiding antibiotic resistance and possible side effects on the human microbiome should be a focus of dentists and physicians. Thus, a sensible administration of antibiotics is mandatory. This manuscript suggests guidelines for a reasonable use.

Evidence-Based Update on Diagnosis and Management of Gingivitis and Periodontitis

This article is an overview to update the practicing general dental practitioner about clinically relevant evidence-based topics published in the recent past in the diagnosis, etiopathogenesis, and management of gingivitis and periodontitis.

Comparing the Antimicrobial In Vitro Efficacy of Amoxicillin/Metronidazole against Azithromycin-A Systematic Review

On account of its proven clinical efficacy, the combination of systemically administered amoxicillin and metronidazole is frequently adjuncted to non-operative periodontal therapy and well documented. Potential drawbacks of this regimen, e.g., side effects and problems with the compliance, led to an ongoing search for alternatives. Azithromycin, an antibiotic extensively used in general medicine, has recently found its niche in periodontal therapy as well. This systematic review aimed to analyze the in vitro antimicrobial efficacy of amoxicillin plus metronidazole versus azithromycin. For this purpose, a systematic literature search was performed, and studies published up to 29 March 2018 referenced in Medline, Embase, Cochrane, and Biosis were independently screened by two authors. An additional hand search was performed and studies focusing on the evaluation of in vitro antimicrobial efficacy of amoxicillin + metronidazole or azithromycin on bacteria from the subgingival biofilm were included. English and German language research reports were considered. From 71 identified articles, only three articles were eligible for inclusion. These studies showed heterogeneity in terms of analytical methods and strains explored. However, all studies used multispecies biofilm models for analysis of the antimicrobial activity. Unanimously, studies reported on more pronounced antimicrobial effects when applying the combination of amoxicillin + metronidazole, compared to azithromycin. Based on the few studies available, the combination of amoxicillin + metronidazole seemed to display higher antimicrobial efficacy in vitro than azithromycin.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Influence of obesity on the outcome of non-surgical periodontal therapy - a systematic review

BACKGROUND

Obesity and periodontitis are important chronic health problems. Obesity is associated with an increased prevalence of periodontitis. Whether obesity also affects the outcome of non-surgical periodontal therapy is to date still unclear.

METHODS

A systematic review of studies referenced in SCOPUS, MEDLINE, PubMed, Cochrane, CINAHL, Biosis and Web of Science was performed. 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. Probing pocket depth reduction was analyzed as primary surrogate parameter for therapeutic success after non-surgical periodontal therapy.

RESULTS

One-hundred-and-fifty-nine potentially qualifying studies were screened. Eight studies fulfilled the inclusion criteria and were analyzed. Three of eight studies failed to show an influence of obesity on pocket depth reduction after non-surgical therapy. The remaining five studies documented a clear negative effect on the outcome of non-surgical periodontal therapy. The finally included studies did not correspond to the highest level of quality (RCTs). Due to the heterogeneity of the data a meta-analysis was not possible.

CONCLUSION

The literature on the effect of obesity on the treatment outcome of non-surgical periodontal therapy remains controversial. The data, however, support that obesity is not only a factor associated with poorer periodontal health but might also result in inferior response to non-surgical treatment of periodontitis.

Clinical Efficacy of Azithromycin as an Adjunctive Therapy to Non-Surgical Periodontal Treatment of Periodontitis: A Systematic Review and Meta-Analysis

INTRODUCTION

Over the years, numerous trials have sufficiently documented benefits of adjuvant administration of antibiotics in combination to Scaling and Root Planing (SRP) in treatment of periodontitis. Nevertheless there are justified doubts in respect to antibiotics administration with regard to increasing development of resistances.

AIM

The aim of this review study and meta-analysis was to verify a possible benefit of Azithromycin (AZM) as an alternative adjuvant antibiotic in combination with SRP.

MATERIALS AND METHODS

Electronic databases (Pubmed) were searched from the earliest point of record until May 2015. A hand search was also conducted. The variables considered in this respect were Probing Depth (PD), Clinical Attachment Level (CAL), Bleeding on Probing (BOP) and SRP. A meta-analysis containing trials comparing SRP as a sole therapy with SRP and administration of AZM was produced once all of the data obtained had been reviewed.

RESULTS

Six randomised clinical trials were accepted into the review and the meta-analysis following the process of trial selection. Meta-analysis revealed larger overall effects by the systemic administration of AZM compared with SRP on their own in terms of PD, CAL, BOP, Plaque-Index and total bacterial load reduction after three and six months.

CONCLUSION

The data used in this study revealed that the systemic administration of AZM is beneficial compared with SRP on its own for the treatment of chronic periodontitis.

Azithromycin recovers reductions in barrier function in human gingival epithelial cells stimulated with tumor necrosis factor-α

OBJECTIVE

The gingival epithelium plays an important role in protecting against the invasion of periodontal pathogens, and the permeability of gingival epithelial cells has been implicated in the initiation of periodontitis. Azithromycin (AZM) has been used in the treatment of chronic inflammatory airway diseases because it regulates cell-cell contact in airway epithelial cells. Therefore, AZM may also regulate barrier function in gingival epithelial cells. In the present study, we examined the effects of AZM on the permeability of human gingival epithelial cells (HGEC) under inflammatory conditions in vitro.

MATERIALS AND METHODS

HGEC were stimulated by tumor necrosis factor-α (TNF-α) in the presence of AZM or p38 MAP kinase and ERK inhibitors. Permeability was assessed based on transepithelial electrical resistance (TER). The expression of E-cadherin, phosphorylated p38 MAP kinase, and ERK was analyzed by Western blotting.

RESULTS

TNF-α decreased TER in HGEC, and AZM and the p38 MAP kinase and ERK inhibitors recovered this decrease. AZM inhibited the phosphorylation of ERK and p38 MAP kinase in TNF-α-stimulated HGEC. Furthermore, AZM recovered the decrease in E-cadherin expression in HGEC stimulated with TNF-α.

CONCLUSIONS

These results suggested that AZM regulated gingival epithelial permeability through p38 MAP kinase and ERK signaling, and may contribute to suppress the inflammation in gingival tissue.