Non-surgical periodontal treatment in conjunction with 3 or 7 days systemic administration of amoxicillin and metronidazole in severe chronic periodontitis patients. A placebo-controlled randomized clinical study

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.

Adjunctive systemic antibiotic effect on periodontal state, salivary enzyme activity, and glycemia imbalance in type-2 diabetics after non-surgical periodontal management

AIM

The current study aimed at analyzing the effect of non-surgical periodontal treatment accompanied by systemic antibiotics on salivary enzyme activities, periodontal parameters, and glycemic control in type-2 diabetic (T2D) patients with chronic periodontitis.

METHODS

The study included 125 type-2 diabetic patients with chronic periodontitis who had good glycemic control (T2Dc), 125 type-2 diabetics who had bad glycemic control (T2Dpc). The 125 T2Dpc were divided randomly into two groups. The first one enrolled 63 T2Dpc and received a non-surgical periodontal treatment (T2Dpc + NST). The second group enrolled 62 T2Dpc and received the non-surgical treatment accompanied by systemic antibiotics (T2Dpc+NST+A). HbA1c, periodontal indices, and salivary enzyme activities were assessed for all groups. The Glycated hemoglobin (HbA1c) was assessed. The Salivary alkaline phosphatase (ALP), aspartate aminotransferase (AST), alanine aminotransaminase (ALT), lactate dehydrogenase (LDH), and creatine kinase (CK) activities were measured.

RESULTS

The T2Dpc were characterized by the highest probing depth (PPD) and clinical attachment loss (CAL) periodontal scores, as well as ALP, AST, and ALT enzymatic activities. However, BOP did not differ significantly between T2Dc and T2Dpc. Whereas the rest of clinical parameters PI, GI, and OHI-S did not significantly differ between groups. The Pearson's analysis revealed three correlations between ALP-PPD, ALP-CAL, and ALP-BOP (bleeding on probing) in both T2Dc and T2Dpc (P < 0.05). Interestingly, a significant decrease in periodontal indices, salivary enzyme activities, and HbA1c was recorded in T2Dpc+NST+A group.

CONCLUSION

The increase in ALP, AST, and ALT activities reflects the impact of uncontrolled T2D on periodontal tissue alteration. The ALP activity increase was associated with the severity of periodontal status in diabetic patients. In comparison to non-surgical treatment alone, the adjunct use of systemic antibiotics improves periodontal state, enzyme activity, and glycemic control.

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.

Periodontal therapy for localized severe periodontitis in a patient receiving fixed orthodontic treatment: a case report

BACKGROUND

Orthodontic treatment involves movement of teeth by compression and resorption of the alveolar bone using orthodontic forces. These movements are closely linked to the interactions between the teeth and the periodontal tissues that support them. Owing to an increase in adults seeking orthodontic treatment, orthodontists increasingly encounter patients with periodontal diseases, in whom orthodontic treatment is contraindicated. In rare cases, periodontitis may develop after treatment initiation. However, no approach for treating periodontitis after the initiation of orthodontic treatment has been established. Here, we present an approach for managing localized severe periodontitis manifesting after initiating orthodontic treatment.

CASE PRESENTATION

A 32-year-old Japanese woman was referred to the Department of Dentistry and Oral Surgery by an orthodontist who observed symptoms of acute periodontitis in the maxillary molars that required periodontal examination and treatment. A detailed periodontal examination, including oral bacteriological examination, revealed localized severe periodontitis (stage III, grade B) in the maxillary left first and second molars and in the mandibular right second molar. After consultation with the orthodontist, the orthodontic treatment was suspended based on the results of the bacteriological examination to allow for periodontal treatment. Full-mouth disinfection was performed with adjunctive oral sitafloxacin. Periodontal and bacteriological examinations after treatment revealed regression of the localized periodontitis with bone regeneration. Thereafter, orthodontic treatment was resumed, and good progress was achieved.

CONCLUSIONS

Orthodontists should recognize the risk of acute severe periodontitis in young adults. Asymptomatic patients with localized severe periodontitis may clear a screening test before orthodontic treatment but develop acute symptoms with bone resorption during orthodontic treatment. Therefore, patients requiring orthodontic treatment should be examined by their family dentist or a periodontist to rule out periodontal issues that may impede orthodontic treatment. The patients should also be informed of age-related risks. Further, periodontists, family dentists, and orthodontists who treat adults should be informed about periodontitis and the need for interdisciplinary collaboration. In patients who develop periodontitis after orthodontic treatment initiation, temporary interruption of orthodontic treatment and aggressive periodontal intervention may facilitate recovery.

Clinical, microbiological and immunological effects of 3- or 7-day systemic antibiotics adjunctive to subgingival instrumentation in patients with aggressive (stage III/IV grade C) periodontitis: a randomized placebo-controlled clinical trial

AIM

To evaluate the clinical non-inferiority of a 3-day-protocol of systemic antibiotics adjunctive to subgingival instrumentation (SI) compared to a 7-day-protocol in patients with stage III/IV grade C periodontitis.

METHODS

50 systemically healthy patients (32.7±4.3 years) with aggressive periodontitis (stage III/IV grade C periodontitis) were treated by SI and adjunctive amoxicillin and metronidazole randomly assigned to group A: (n=25) 500mg antibiotics 3-times-daily for 3 days, followed by placebo 3-times-daily for 4 days, or group B: (n=25) 500mg AB 3-times-daily for 7 days. Clinical, microbial and immunological parameters were assessed at baseline, 3 and 6 months, and patient-related outcomes after 2 weeks. The primary outcome variable was the number of residual sites with PD≥6mm at 6 months.

RESULTS

For the primary outcome variable (the number of residual sites with PD≥6mm at 6 months), the null hypothesis was rejected and demonstrated the non-inferiority of the 3d AB protocol compared to 7d AB (the upper limits of the 95%CI for ITT: [-2.572; 1.050] and PP: [-2.523; 1.318] were lower than the assumed margin of Δ=3.1). Comparable clinical improvements were obtained for all parameters with both antibiotic protocols (p>0.05). All investigated periodontopathogens and pro-inflammatory host-derived markers were statistically significantly reduced, without differences between the treatments (p>0.05).

CONCLUSION

These findings indicate that in patients with aggressive periodontitis (stage III/IV grade C periodontitis), a 3-day systemic administration of amoxicillin and metronidazole adjunctive to SI may lead to non-inferior clinical outcomes after 6-months with fewer adverse events compared to a 7-day-protocol.

Influence of Anti-Infective Periodontal Therapy on Subgingival Microbiota Evaluated by Chair-Side Test Compared to qPCR—A Clinical Follow-Up Study

A chair-side test (CST) for five periodontal pathogens (Aggregatibacter actinomycetemcomitans, A.a.; Porphyromonas gingivalis, P.g.; Prevotella intermedia, P.i.; Treponema denticola, T.d.; Tannerella forsythia, T.f.) was compared with qPCR in a previous clinical study on 100 periodontitis patients at first diagnosis (T0). Following non-surgical treatment alone (SRP) or in combination with systemic or local antibiotics, 74 patients (57.4 ± 13.5 years) were again tested at the same sites from 14 to 24 months after T0. Bacterial elimination (%; compared to T0) was determined for each single species and compared between both test systems. In all patients, all five pathogens could not be fully eliminated regardless of therapy or test method. Tested with CST, the mean elimination ranged from 90% for SRP + Amoxicillin/Metronidazole to 59.13% for SRP only. The corresponding qPCR values were 30% and 29.6%. Only A.a. was eradicated in 100% by SRP + Amoxicillin/Metronidazole tested by CST, and it was 80% when qPCR was the test method. CST agreed with qPCR in 98.7% in the detection of A.a., and 74.3%, 78.4%, 73.0%, and 48.7% for P.g., P.i., T.d., and T.f., respectively. Neither conventional treatment nor the additional use of antibiotics—even with the correct indication—could completely eradicate the tested pathogens or prevent pocket reinfection.

Estimating daily antibiotic harms: an umbrella review with individual study meta-analysis

BACKGROUND

There is growing evidence supporting the efficacy of shorter courses of antibiotic therapy for common infections, however the risks of prolonged antibiotic duration are underappreciated.

OBJECTIVES

We sought to estimate the incremental daily risk of antibiotic-associated harms.

METHODS

We searched three major databases to retrieve systematic reviews from 2000 to July 30, 2020 in any language.

ELIGIBILITY

Systematic reviews were required to evaluate shorter versus longer antibiotic therapy with fixed durations between 3 and 14 days. RCTs included for meta-analysis were identified from the systematic reviews.

PARTICIPANTS

Adult and pediatric patients from any setting.

INTERVENTIONS

Primary outcomes were the proportion of patients experiencing adverse drug events, superinfections and antimicrobial resistance. Risk of Bias Assessment: Each RCT was evaluated for quality by extracting the assessment reported by each systematic review.

DATA SYNTHESIS

The daily odds ratio (OR) of antibiotic harm was estimated and pooled using random effects meta-analysis.

RESULTS

Thirty-five (35) systematic reviews encompassing 71 eligible randomized controlled trials were included. Studies most commonly evaluated duration of therapy for respiratory tract (n=36, 51%) and urinary tract infections (n=29, 41%). Overall, 23,174 patients were evaluated for antibiotic-associated harms. Adverse events (n=20,345), superinfections (n=5,776), and AMR (n=2,330) were identified in 19.9% (n=4,039), 4.8% (n=280), and 10.6% (n=246) of patients, respectively. Each day of antibiotic therapy was associated with 4% increased odds of experiencing an adverse event (OR 1.04, 95% CI [1.02 to 1.07]). Daily odds of severe adverse effects also increased (OR 1.09, 95% CI [1.00 to 1.19). The daily incremental odds of superinfection and AMR were OR 0.98 (0.92 to 1.06) and OR 1.03 (0.98 to 1.07), respectively.

CONCLUSION

Each additional day of antibiotic therapy is associated with measurable antibiotic harm, particularly adverse events. These data may provide additional context for clinicians when weighing benefits versus risks of prolonged antibiotic therapy.

The effect of drug dose and duration of adjuvant Amoxicillin-plus-Metronidazole to full-mouth scaling and root planing in periodontitis: a systematic review and meta-analysis

OBJECTIVES

The aim is to explore the optimal drug dose and duration of adjunctive Amoxicillin-plus-Metronidazole (AMX/MET) to full-mouth scaling and planing (FMSRP) in periodontitis.

METHODS

An electronic search in four databases and manual search in four journals were conducted for randomised clinical trials comparing AMX/MET adjunct to FMSRP with FMSRP alone for at least 3 months.

RESULTS

Eleven studies were eligible and included. The primary outcome was clinical attachment level (CAL) gain, the secondary outcomes were periodontal pocket depth (PPD) reduction and adverse events. Our results showed a beneficial effect of adjunctive AMX/MET with higher drug dose to FMSRP for CAL gain and PPD reduction at 3 months, and the benefit remained stable at 6 months. However, minimal difference among three-seven-and ten-day drug duration was observed. In addition, the risk difference of adverse events was minimal between two groups.

CONCLUSION

FMSRP adjunct to a high drug dose of 500/500 mg of AMX/MET showed a significant and stable improvement on 6-month follow-up period. No decision for drug duration could be made due to limited evidence.

CLINICAL RELEVANCE

On 6-month follow-up, higher dose of AMX/MET adjunct to FMSRP could provide a stable clinical effect. No recommendation for drug duration could be made.

Efficacy of antibiotic versus probiotics as adjuncts to mechanical debridement for managing peri-implant mucositis

The objective was to compare the efficiency of probiotic (PT) versus antibiotic therapy (AT) as adjuvants to non-surgical-mechanical debridement (NSMD) in the treatment of peri-implant mucositis (Pi-M). Volunteers with Pi-M were encompassed. Therapeutically, patients were randomly divided into 3-groups: (a) Group-1: NSMD + PT; (b) Group-2: NSMD + AT; and (c) Group-3: NSMD alone. Peri-implant plaque index (P.I), bleeding on probing (B.O.P), probing depth (P.D) and crestal-bone-loss (C.B.L) were recorded at baseline and at 3-and 6-months follow-up. P<0.05 was selected as the indicator of statistical significance. Forty-two male individuals (14, 14 and 14 in groups 1, 2 and 3, respectively) were included. At 3- and 6-months of follow-up, P.I (P<0.01), B.O.P (P<0.01) and P.D (P<0.01) were higher in Group-2 than Group-1. At 3-months of follow-up, P.I (P<0.01), B.O.P (P<0.01) and P.D (P<0.01) were higher in Group-3 than Group-2. At 6-months of follow-up, P.I, B.O.P and P.D were comparable in groups 2 and 3. In Group-3, P.I, B.O.P and P.D were comparable with the respective baseline values at 6-months of follow-up. The C.B.L in all groups remained unchanged up to 6-months of follow-up. The NSMD with adjuvant PT is more effective than adjunct AT in the treatment of Pi-M for up to 3-months.

Adjunctive systemic antimicrobials in the treatment of chronic periodontitis: A systematic review and network meta-analysis

The aim of this systematic review and network meta-analysis was to assess the efficacy of antimicrobials adjunctive to scaling and root planing (SRP) in the treatment of chronic periodontitis. The study was conducted according to the PRISMA statement. The protocol (CRD42020178621) was registered on the International Prospective Register of Systematic Reviews (PROSPERO). The MEDLINE, EMBASE, and CENTRAL databases were searched up to March 2020; furthermore, a manual search of relevant periodontal journals was conducted. Mean differences (MD) and standard deviations were calculated for clinical attachment level (CAL) gain and probing depth (PD) reduction at 6 and 12 months. A network meta-analysis was performed to assess direct and indirect comparisons and to establish a ranking of treatments. A total of 21 randomized clinical trials (RCTs) were included in the systematic review. Network meta-analysis showed that SRP + amoxicillin (AMX) + metronidazole (MTZ), as compared to SRP, reached the highest PD reduction at 6 [MD = 0.47; 95% CI (0.3; 0.64)] and 12 months [MD = 0.51; 95% CI (0.25; 0.78)], and CAL gain at 6 [MD = 0.54; 95% CI (0.27; 0.8)] and 12 months [MD = 0.37; 95% CI (0.05; 0.69)]. Network meta-analysis indicated that AMX + MTZ adjunctive to SRP provided the best improvement in clinical parameters, followed by SRP + MTZ.

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.

Non-Surgical Periodontal Therapy with Adjunctive Amoxicillin/Metronidazole or Metronidazole When No Aggregatibacter actinomycetemcomitans Is Detected—A Randomized Clinical Trial

Background: The aim was to compare two different systemic antibiotics regimens adjunctive to non-surgical periodontal therapy when Aggregatibacter actinomycetemcomitans was not detected in the subgingival biofilm. Methods: A total of 58 patients with periodontitis and with no A. actinomycetemcomitans in the subgingival biofilm were treated with full-mouth subgingival instrumentation and either metronidazole (MET; n = 29) or amoxicillin/metronidazole (AMX/MET; n = 29). Probing depth (PD), clinical attachment level (CAL) and bleeding on probing (BOP) were recorded at baseline, as well as after three and six months. Subgingival biofilm and gingival crevicular fluid were collected and analyzed for major periodontopathogens and biomarkers. Results: PD, CAL and BOP improved at 3 and 6 months (each p < 0.001 vs. baseline) with no difference between the groups. Sites with initial PD ≥ 6 mm also improved in both groups after 3 and 6 months (p < 0.001) with a higher reduction of PD in the AMX/MET group (p < 0.05). T. forsythia was lower in the AMX/MET group after 3 months (p < 0.05). MMP-8 and IL-1β were without significant changes and differences between the groups. Conclusion: When A. actinomycetemcomitans was not detected in the subgingival biofilm, the adjunctive systemic use of amoxicillin/metronidazole results in better clinical and microbiological outcomes of non-surgical periodontal therapy when the application of systemic antibiotics is scheduled.

Microbiological and host-derived biomarker evaluation following non-surgical periodontal therapy with short-term administration of systemic antimicrobials: secondary outcomes of an RCT

Nonsurgical periodontal therapy with adjunctive use of systemic antimicrobials (for 7-14 days) showed improved clinical, microbiological and immunological results over the mechanical protocol alone. Considering the increasing risk for antimicrobial resistance with longer antibiotic regimes, it is important to establish the optimal antibiotic protocol with a maximum antimicrobial benefit and minimum risk for adverse effects. The aim of the study was to evaluate the microbiological and inflammatory outcomes 12-months after a 3-/7-day systemic antibiotic protocol [amoxicillin (AMX) + metronidazole (MET)] adjunctive to subgingival debridement in severe periodontitis compared to mechanical treatment alone. From the initially treated 102 patients, 75 subjects (Placebo group: n = 26; 3-day AMX + MET group: n = 24; 7-day AMX + MET group: n = 25) completed the 12-month examination. Clinical parameters, eight periodontal pathogens and inflammatory markers were determined at baseline and 3-, 6-, 12-months after therapy using real-time PCR and ELISA respectively. After 6 months, several periodontopathogens were significantly more reduced in the two antibiotic groups compared to placebo (p < 0.05). After 1 year, both antibiotic protocols showed significant reductions and detection of the keystone pathogen P. gingivalis compared to placebo. Antibiotic protocols, smoking, disease severity, baseline-BOP, -CAL and -IL-1β, as well as detection of T. denticola at 12-months significantly influenced the residual number of deep sites. The present data indicate that the systemic use of both short and longer antibiotic protocols (AMX + MET) adjunctive to nonsurgical periodontal therapy lead to higher microbiological improvements compared to subgingival debridement alone. The two investigated antibiotic protocols led to comparable microbiological and inflammatory results.

Influence of local anesthesia on the outcomes of non-surgical periodontal treatment

BACKGROUND

There is limited evidence of the effects of local anesthesia (LA) on outcomes of non-surgical periodontal treatment (NSPT), in particular among the Chinese. This retrospective cohort study aimed to evaluate the effects of LA on short-term treatment outcomes of NSPT and to determine under what circumstances LA should be prescribed to improve these outcomes.

METHODS

Data from periodontal examinations of 3980 patients were used. The data were from 3-month re-evaluation records of an electronic periodontal charting record system in the Department of Periodontology of Peking University School and Hospital of Stomatology from June 2008 to January 2015. Descriptive analyses included changes in probing depth (PD) and the Mazza bleeding index (BI). Two-level (patient and tooth) logistic regression models and three-level (patient, tooth, and site) linear regression models were constructed to analyze the influence of LA on PD for all teeth/sites and teeth/sites with an initial PD ≥ 5 mm. Decreases in PD and BI at sites under LA using the initial PD were also compared.

RESULTS

A significantly higher mean decrease in PD after NSPT was found in the LA group than in the no local anesthesia (NLA) group (0.98 vs. 0.54 mm, t = 24.12, P < 0.001). A significantly higher probability of decreases was found in the LA group in BI (percentages of teeth with BI > 1 and BI > 2) for all teeth (16.7% vs. 13.8%, t = 3.75, P < 0.001; 34.7% vs. 28.1%, t = 6.73, P < 0.001) and PD for teeth with PD ≥ 5 mm (32.3% vs. 17.3%, t = 28.48, P < 0.001). The difference in PD between the LA and NLA groups increased as the initial PD increased. The difference between the two groups was 0.12 to 0.22 mm for sites with a baseline PD < 7 mm; however, it increased to 0.41 to 1.37 mm for sites with a baseline PD ≥ 7 mm.

CONCLUSIONS

LA improved the decrease in PD after NSPT. Root debridement at sites with initial PD ≥ 7 mm should be performed under routine LA.

Influence of psychological stress on non-surgical periodontal treatment outcomes in patients with severe chronic periodontitis

BACKGROUND

The aim of this study was to evaluate the influence of psychological stress on non-surgical periodontal treatment (SRP) outcomes in patients with severe chronic periodontitis (stage 3/4 generalized periodontitis) at 6 months in the French population.

METHODS

Patients diagnosed with severe generalized chronic periodontitis (periodontitis stage 3/4) were included in this study. At baseline, psychological status was evaluated by self-administered questionnaire (Depression Anxiety Stress Scale 42 [DASS-42] and Toulouse coping scale [TCS]). Plasma levels of cortisol and chromogranin-A were determined. Patients were then managed by oral hygiene instructions, scaling and root planing of sites with PD >3 mm and followed at 3 and 6 months. Quantitative and qualitative variables were described and interactions were determined by linear and logistic regressions.

RESULTS

Seventy-one patients were included in this study and 54 were followed up to 6 months. An average probing depth (PD) reduction of 0.73 ± 0.11 mm and decrease of diseased sites (PD >3 mm) were measured at 6 months illustrating SRP efficacy. Multivariable analysis showed that increased DASS-stress score was associated to worsened SRP outcomes in terms of bleeding on probing (BOP) (OR = 1.02, P <0.05) and mean PD (P <0.05) reduction. An increase of DASS-depression score negatively influenced PD >5 mm (OR = 1.06, P <0.05), PD >7 mm (OR = 1.17, P <0.01), CAL >5 mm (OR = 1.03, P <0.05), and CAL >7 mm (OR = 1.07, P <0.05) reduction. Negative coping strategies were also associated with worsened SRP outcomes.

CONCLUSIONS

Patients with increased stress, anxiety, and depression scores as well as those exhibiting negative coping strategies demonstrate worsened SRP outcomes. DASS-42 and TCS were useful to determine psychological status and their use could be incorporated to assess treatment prognosis.

The effect of the systemic folic acid intake as an adjunct to scaling and root planing on clinical parameters and homocysteine and C-reactive protein levels in gingival crevicular fluid of periodontitis patients: A randomized placebo-controlled clinical trial

AIM

To evaluate clinical and biochemical effects of adjunctive systemic folic acid (FA) intake with scaling and root planing (SRP) in periodontitis treatment.

MATERIALS AND METHODS

Sixty periodontitis subjects (30 per group) were randomly assigned into study groups and treated with either SRP + placebo (SRP + P) or SRP + folic acid (SRP + F). In addition to clinical parameters (plaque index [PI], gingival index [GI], probing pocket depth [PPD], clinical attachment level [CAL] and gingival recession [GR]), gingival crevicular fluid (GCF) samples were obtained at baseline and post-treatment (PT) periods (one (PT-1), three (PT-3) and six (PT-6) months) for C-reactive protein (CRP) and homocysteine (Hcy) evaluation.

RESULTS

Significant time-dependent reduction was detected at all clinical parameters for both groups (p < .001). Compared to SRP + P, CAL was lower in SRP + F at PT-1 (p = .004) and PT-3 (p = .035), whereas GR was lower at only PT-1 (p = .015). GCF volume and CRP did not show inter-group differences, whereas Hcy was higher in SRP + F at PT-3 (p = .044) and PT-6 (p = .041). GCF volume and Hcy showed reduction after treatment in both groups (p < .001).

CONCLUSION

Both modalities exhibited clinical improvement and change in biochemical parameters. Adjunctive systemic FA intake may be recommended adjunctive to periodontitis treatment to reveal better outcomes. However, its impact mechanisms should be further enlightened.

Gingival recession after scaling and root planing with or without systemic metronidazole and amoxicillin: a re-review

BACKGROUND

Gingival recessions inevitably occur during healing after scaling and root planing, but synoptic data on this topic is still lacking. This review compared the recession formation with and without the administration of systemic antibiotics.

OBJECTIVES

To evaluate the formation of recession with and without the administration of antibiotics during the healing after scaling and root planing.

MATERIALS AND METHODS

This study re-analyzed publications that reported clinical attachment levels (CAL) and probing pocket depths (PD) up to January 2019, including the pivotal review by Zandbergen and co-workers (2013). Whereas these studies traditionally focused on PD and CAL, the present analysis compared recession formation (ΔREC) after adjunctive systemic administration of amoxicillin (amx) and metronidazole (met) during scaling and root planing (SRP) and SRP alone. The mean increase in ΔREC, if not reported, was calculated from CAL and PD values and statistically analyzed. Recession formation was compared after 3 and 6 months after therapy. Results were separately reported for chronic periodontitis (CP) as well as aggressive periodontitis (AP) cases.

RESULTS

Recessions increased consistently between baseline and follow-up. In the AP group, median ΔREC was 0.20 mm after 3 months, irrespective of whether antibiotics were administered or not. After 6 months, median ΔREC increased to 0.35 mm after AB and remained stable at 0.20 mm with SRP alone. In the CP group, after 3 months with and without antibiotics, median ΔREC accounted for 0.30 mm and 0.14 mm, respectively. After 6 months, median ΔREC accounted for 0.28 mm (with AB) and 0.20 mm (without AB). The quantitative assessment by meta-analyses also yielded small values (≤ 0.25 mm) for the estimated differences in recession formation between AB and noAB; however, none of them reached statistical significance.

CONCLUSIONS

Although a slight tendency towards higher recession formation after SRP in combination with AB could be observed in many studies, quantitative meta-analyses showed no clinically relevant difference in recession formation due to the administration of AB. In general, the description and discussion of recessions in the literature seems not to be a major focus so far.

CLINICAL RELEVANCE

Since the preservation of gingival tissues is important by preventive and therapeutic means, e.g., when avoiding postoperative root sensitivity or performing regenerative surgery, these aspects should not be neglected. We thus suggest to report REC measurements along with PD and CAL values for more direct recession formation (ΔREC) assessments in the future.

Clinical, microbiological and oxidative stress evaluation of periodontitis patients treated with two regimens of systemic antibiotics, adjunctive to non-surgical therapy: A placebo-controlled randomized clinical trial

Aim of research was to evaluate and compare the clinical and microbiological effects of two different regimens of amoxicillin (AMX) and metronidazole (MTZ) combined with non-surgical periodontal therapy in patients with chronic periodontitis (CP), and identify antibiotic-resistant bacteria and changes in oxidative stress (OS). Forty-six patients with generalized CP were randomly assigned to group A [scaling and root planing within 24 h (SRP) + placebo for 7 days), group B [SRP + AMX + MTZ, both 500 mg three times daily (TID), 3 days), and group C [SRP + AMX + MTZ, both 500 mg TID, 7 days). Periodontal pocket depth (PPD-primary outcome), clinical attachment level (CAL), full-mouth bleeding scores (FMBS), plaque scores (FMPS), blood and subgingival plaque were assessed at baseline and after three months. OS was evaluated via derivatives of reactive oxygen metabolites (d-ROMs) and assessments of biological antioxidant potential (BAP). Bacterial profiling was performed by PCR. Antibiotic resistance was evaluated in cultures. PPD, CAL, number of sites with PPD ≥6 mm, their PPD, CAL and FMBS decreased (P<0.05) in all groups, as well as FMPS in groups A and B, and d-ROMs in group C. There were significant differences among groups regarding decreases in the frequency of detection for Aa and Tf. For Aa, there were differences between groups A and C (P=0.048) and between groups B and C (P=0.048), but not between groups A and B; whereas for Tf, groups A and B were different from group C (P<0.001), but not from each other (P=0.920). No resistance to AMX was identified prior to treatment; two strains were resistant after treatment. Before treatment, 13 strains were resistant to MTZ, and 2 were resistant after. One strain in the same patient was sensitive prior to treatment, and later became resistant to both antibiotics. SRP with a 7-day course of antibiotic therapy was more effective for improving clinical parameters, in decrease of detection of several periopathogens, and in improvement of OS when compared to a 3-day regimen. Resistance was found in fewer strains after treatment than before.

One year results of a randomized controlled clinical study evaluating the effects of non-surgical periodontal therapy of chronic periodontitis in conjunction with three or seven days systemic administration of amoxicillin/metronidazole

BACKGROUND

To evaluate the clinical outcomes 12 months after systemic administration of amoxicillin (AMX) and metronidazole (MET) adjunctive to subgingival debridement (SD) in patients with severe chronic periodontitis (sChP).

MATERIAL AND METHODS

102 patients with sChP were treated randomly as follows: SD within 2 consecutive days and placebo for 7 days (group A), SD+AMX+MET (both 500mg x3 times daily TID) for 3 days (group B), SD+AMX+MET (both 500mg x 3 TID) for 7 days (group C). At baseline, at 3-, 6-, and 12-months post-treatment probing pocket depth (PD), clinical attachment level (CAL), furcation involvement, bleeding on probing (BOP), full-mouth plaque score (FMPS) were determined. The reduction in the number of sites with PD≥6mm was defined as main outcome variable.

RESULTS

75 patients completed the study. At 12 months, all three treatment groups showed statistically significant improvements (p<0.001) of mean PD, CAL, BOP and number of sites with PD≥6mm compared to baseline. Mean residual PD were statistically significantly lower and CAL gain statistically significantly greater in the two antibiotic groups as compared to placebo. While PD reductions (p = 0.012) and CAL gain (p = 0.017) were statistically significantly higher in group C compared to group A, only the 3-day AB group showed statistically significantly fewer sites with PD≥6mm at 12 m (p = 0.003). The reduction in the number of sites with PD≥6 mm (primary outcome) showed no statistical significant differences between the 3 treatment groups. However, in both antibiotic groups significantly more patients compared to the placebo group reached a low risk for disease progression at 12 months (≤4 sites with PD≥5mm).

CONCLUSION

At 12 months, both adjunctive antibiotic protocols resulted in statistically significantly greater clinical improvements compared to placebo.