Diabetes and periodontal disease two very common chronic diseases. Review have suggested that periodontal treatment may have a positive impact on glycaemic control in diabetics. Reviews have also suggested that adjuvant antibiotic may improve periodontal outcomes.
The aim of this review was to assess the effects of adjunctive use of systemic antibiotics in nonsurgical periodontal treatment, compared to nonsurgical periodontal treatment alone, on metabolic control in patients with diabetes.
Methods
Searches were conducted in the Medline/PubMed, Embase, The Cochrane Central Register of Controlled Trials (CENTRAL), LILACS, BBO (Brazilian Dental Library), the Brazilian database of theses and dissertations (Banco de Teses CAPES). ClinicalTrials.gov, Current Controlled Trials, EU Clinical Trials Register, Australian New Zealand Clinical Trials Registry, and Registro Brasileiro de Ensaios Clínicos (ReBEC) databases. Recent issues of the journals Journal of Dental Research, Journal of Periodontal Research, Journal of Clinical Periodontology and Journal of Periodontology and abstracts from the International Association for Dental Research and the European Federation of Periodontology meetings (EuroPerio 4–7) were also examined.
Randomised controlled trials (RCTs) that assessed changes in glycated haemoglobin (HbA1c) levels in diabetic patients with periodontitis (chronic or aggressive) after scaling and root planing (SRP) combined with systemic antibiotics or sub-antimicrobial doxycycline (SDD) in comparison to SRP alone, with or without a placebo with a follow up of at least 3 months were considered. Two reviewers independently selected studies, abstracted data and assessed risk of bias using the Cochrane tool. Pooled weighted mean differences and 95% confidence intervals for HbA1c were calculated using fixed and random effects models.
Results
- 12 studies involving a total of 452 patients met the inclusion criteria
- None of the 12 studies were at low risk of bias,5 were at high risk the remainder at unclear risk.
- Sample sizes ranged from 19-70 patients.
- Different antibiotics and or regimens were used in the studies.
- Follow up varied from 3-12 months.
- 9 studies included in the meta-analysis.
- Meta-analyses showed no significant effect favouring SRP plus antibiotic for reductions in mean HbA1c (−0.11% [−0.35, 0.13]; 6 studies).
- There was also no significant effect favouring the adjunctive usage of sub-antimicrobial doxycycline in HbA1c mean reduction (−0.19% [−1.04, 0.67]; 2 studies).
- 7 studies reported on adverse effects.
Conclusions
The authors concluded: –
this review was not able to demonstrate that adjunctive use of systemic antibiotic provides a significant benefit in terms of HbA1c improvement in periodontal treatment of patients with diabetes.
Comments
An updated Cochrane review (Dental Elf – 11th Nov 2015) looked the effect of periodontal therapy on glycaemic control in people with diabetes mellitus (DM) identifying 35 RCTs. They found low quality evidence that the treatment of periodontal disease by SRP did improve glycaemic control in people with diabetes, (mean percentage reduction in HbA1c of 0.29% at 3-4 months) although there was insufficient evidence to demonstrate that this is maintained after 4 months.
This new review focuses on the whether the use of adjunctive antibiotics in diabetics had any effect. A good methodological approach was taken using a broad search strategy. Only a small number of small studies met the inclusion criteria and none of the included studies was at low risk of bias. The Cochrane review found no consistent effect for adjunctive antibiotics over SRP alone and while this review included systemic antibiotics it also failed to demonstrate any additional benefit. A small majority of the included studies assessed adverse effects and while these were relatively small in number they included gastrointestinal discomfort, diarrhoea, nausea and vomiting, headaches and metallic taste.
An earlier review of this question (Dental Elf – 12th May 2016) included 13 studies and suggested a small statistically significant benefit. Review of the adjuvant use of antibiotics have also suggested they may be a benefit for non-diabetic patients. However, with all these reviews the clinical benefits are clinically small and the quality of the evidence limited so this together with the possibility of adverse effects for individual patients and the problem of antibiotic resistance needs to be seriously considered.
Links
Primary paper
Lira Junior R, Santos CMM, Oliveira BH, Fischer RG, Santos APP. Effects on HbA1c in diabetic patients of adjunctive use of systemic antibiotics in nonsurgical periodontal treatment: A systematic review. J Dent. 2017 Aug 4. pii: S0300-5712(17)30183-5. doi: 10.1016/j.jdent.2017.08.001. [Epub ahead of print]PubMed PMID: 28827017.
Other references
Dental Elf – 15th Feb 2017
Dental Elf – 12th May 2016
Periodontal treatment- adjuvant antibiotics for diabetic patients?
Dental Elf – 11th Nov 2015
Low quality evidence that periodontal treatment improves glycaemic control in diabetics
