03 June 2022

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Antibiotic therapy in periodontal disease

Edoardo Mancuso

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Periodontal disease is one of the most common chronic inflammatory diseases around the world. If untreated, it may lead to loss of tooth-bearing tissue, apical migration of the junctional epithelium, and ultimately to tooth loss.
Treatment of periodontitis comprises the non-surgical, mechanical removal of the inflammation-associated bacterial biofilms  from tooth structure, accompanied by a regular domestic cleaning executed by the patient and recurring professional maintenance care.
Periodontal disease affects not only the integrity and functions of the periodontium locally, but also leads to a significant increase in the systemic inflammation burden. Indeed, links between periodontal disease and systemic diseases  (diabetes mellitus, cardiovascular diseases, chronic respiratory diseases, and rheumatoid arthritis) have been established. Although the vast majority of clinical intervention studies demonstrate a statistically verifiable added benefit for the use of adjuvant administration of systemic antibiotics  to increase the effectiveness of mechanical therapy, their local and systemic clinical relevance is still controversially discussed.

To evaluate whether there is a meaningful clinical benefit regarding the use of systemic adjunctive antibiotics  in the treatment of patients with periodontitis, Prof. Pretzl has published in 2019, on the Clinical Oral Investigations Journal an interesting consensus report. The consensus report aims to provide decision guidance on adjunctive administration of systemically effective antibiotics in periodontal therapy and to propose indications regarding disease severity and antibiotic selection.

Materials and methods
In the research, a structured systematic literature search was performed by two independent investigators focusing on systematic reviews  and recent randomized clinical trials in two electronic databases (PubMed, Web of Knowledge).

Results
The research conducted at the Heidelberg University resulted in the identification of 296 systematic reviews and 50 potential randomized clinical trials. After exclusion, 19 systematic reviews and six RCTs were selected. The research included were focusing on chronic periodontitis, aggressive periodontitis, and on smokers and diabetic subjects.

Discussion

The effectiveness of antibiotics is significantly reduced in biofilms due to the particular structure of this bacteria agglomerate. Moreover, the necessary effect concentration in periodontal pockets can hardly be reached without disaggregating subgingival plaque mechanically.

For these reasons, the author of the paper states that an essential prerequisite for the use of adjunctive systemic antibiotics during periodontal therapy is the mechanic disruption of the integrity of the subgingival biofilm and its reduction during full-mouth scaling.

The majority of data from meta-analyses and RCTs included in the research showed a significant additional benefit concerning PPD reduction and CAL gain when adjunctive systemic antibiotics were administered in addition to mechanical biofilm removal compared to non-surgical therapy alone.

Professor Pretzel continues assessing that, patient’s age and illness severity can influence the adjunctive effect of systemic antibiosis parallel to full-mouth scaling in certain groups.

For example, only in patients aged 55 years and younger with severe forms of periodontitis, all meta-analyses, RCTs, and CCTs included in the study showed a relevant benefit from the use of adjunctive systemic antibiosis compared to subgingival debridement alone. 

The article then continues focusing on the selection of the correct antibiotic as an adjunct to full-mouth scaling affirming that, due to the plurality of the trials and the numerous antibiotic agents used in the different research, no specific recommendation for any antibiotic or combination of antibiotics can be given. It is then affirmed that most evidence exists for the combination of Amoxicillin and Metronidazole, Metronidazole alone, and Azithromycin. 

Recommendations and statements

The authors continue adding some recommendation in the use of systemic antibiotics:

-      Indirect evidence suggests that adjunctive systemic antibiosis should be initiated in direct context with mechanical debridement.

-      The strongest favorable evidence regarding intake of systemic antibiotics in the context of subgingival mechanical plaque removal and their safety exists for the combination of Amoxicillin and Metronidazole. Alternatively, systemic antibiosis adjunctive to mechanical subgingival plaque removal can be provided with Metronidazole only.

Conclusion
The article concludes by affirming that systemic antibiotics should be sensibly administered and restrictively used in addition to periodontal therapy and that only certain groups of patients show a significant and clinically relevant benefit after intake of systemic antibiosis during periodontal therapy. 

To conclude is always to remember, when prescribing antibiotics, that there is a possibility to establish antibiotic resistance in our patients and negatively modify the human microbiome as a negative effect of antibiotic usage. Moreover, before administering any form of periodontal therapy an accurate diagnosis of periodontal disease is needed. This requires an adequate anamnesis as well as periodontal status including PPD, clinical attachment levels (CAL), and BOP. Adjunctive systemic antibiotics shall then only be considered if the severity and extent of the disease, as well as history of medication, are taken into account.

For additional Information: https://link.springer.com/article/10.1007/s00784-018-2727-0