Azithromycin as an adjunct to scaling and root planing for periodontal disease

Reviews have suggested that the use of systemic antibiotics provide a useful adjunct to scaling and root planing (SRP) for the management of periodontal disease. However there are concerns regarding antibiotic resistance and adverse events regarding metronidazole and amoxicillin two of the most commonly used antibiotics. Azithromycin (AZM), a broad-spectrum, second-generation macrolide with promising pharmacokinetic qualities that has been used in some periodontal studies. The aim of this review was to evaluate the effect of systemically administered azithromycin (AZM) as an adjuvant to SRP in non-surgical periodontal therapy.

Methods

Searches were conducted in the Medline, Embase, Cochrane Library and Open Grey databases. Two reviewers selected studies for inclusion. Randomised controlled trials (RCTs)Investigating the effects of systemically administered AZM on non-surgical periodontal therapy published in German or English were considered. Study quality was assessed using the Cochrane risk of bias tool. The primary outcome measure was tooth loss; changes in pocket depth (PD), clinical attachment level (CAL) and adverse effects were secondary outcomes. A narrative summary was presented.

Results

9 studies involving a total of 338 patients were included
The studies were considered to have a moderate to low risk of bias.
7 studies used a AZM dosage of 500 mg once daily for 3 days
5 studies used a placebo control
Chronic periodontitis (ChP)
- Data on tooth loss as an outcome were reported by one study
- 5 out of 7 studies documented a beneficial effect of systemically administered AZM compared to SRP in terms of the PD measures
- In 3 of the 7 studies, the changes in CAL differed significantly between test and control groups after 6 months or 12 months
Aggressive periodontitis (AgP)
- 1 of the 2 studies reported a positive effect of AZM revealing a significantly higher percentage of teeth with a PD decrease of ≥2 mm in the test group.
- 5 studies reported minor adverse events, gastrointestinal reactions or headache and dizziness.

Conclusions

The authors concluded:

several studies in different populations have explored a possible beneficial effect of the adjunctive use of AZM on periodontal non-surgical treatment of ChP or AgP patients. For the therapy of both diseases, there are, however, no data available on the superiority of AZM against the standard antibiotic combination of metronidazole and amoxicillin.

Comments

Three major databases and the grey literature have been searched for this review but limiting the language to German and English may have resulted in some studies being excluded. Only 9 small RCTs have been included and the authors decided against conducting a meta-analysis owing to marked heterogeneity between the studies.

Previous systematic reviews (Dental Elf – 16^th Mar 2015 & 20^th Jul 2015) have looked more broadly at systemic antibiotics as adjuncts to non-surgical periodontal treatment for management of periodontal disease and included some studies assessing the use of AZM. While these studies suggest some benefit from antibiotic use the limited quality of the available evidence and the small additional benefit together with the growing problem of antibiotic resistance does suggest that their use should be highly selective if at all.