Diabetes is considered to be a risk factor for periodontal disease and reviews have suggested that periodontal treatment improves control of HB1Ac. Reviews have also suggested that the use of systemic antibiotics might improve periodontal outcomes in some populations.

The aim of this study was to review randomized clinical trials assessing systemic antimicrobial use adjuvant to scaling and root planing (SRP) versus SRP alone in diabetic patients.

Methods

Searches were conducted in the PubMed/MEDLINE, Cochrane-CENTRAL, EMBASE, TRIP, ISI Web of Science, LILACS, clinical trials registry and OpenGrey databases. This was supplemented by searches of the Journal of Clinical Periodontology, Journal of Periodontal Research and Journal of Periodontology.

Clinical trials involving diabetic patients with periodontitis comparing scaling and root planing alone or with placebo against SRP and systemic antimicrobials were considered. Two reviewers independently selected studies, abstracted data and assessed risk of bias. The risk of bias assessment was based on the Cochrane handbook. Data analysis followed Cochrane statistical guidelines.

Results

• 13 RCTs were included
• Follow up periods range from 3-12 months
• Risk of bias was considered low in most studies
• Prescribed antibiotics varied in type and dosage (amoxicillin/clavulanic acid, 875 mg; doxycycline, 20/100/ 200 mg; azithromycin, 500 mg; metronidazole, 400 mg + amoxicillin, 500 mg; once, twice and three times a day) and period of intake (3, 13, 14, or 15 days; 3 or 6 months).
• Meta-analysis (11 studies) found a statistically significant improvement in probing depth with antibiotic use; Weighted mean difference (WMD) = -0.15 mm (95% CI; -0.24 to -0.06)
•  No statistical differences were seen in WMD for CAL gain, PI and BOP reductions.
• Adverse effects were reported in 3 studies. These included dizziness and difficulty swallowing, gastrointestinal discomfort, diarrhoea, headache, metallic taste, nausea, vomiting and irritability

Conclusions

The authors concluded:-

Our results seem to support the adjunctive clinical benefits of antimicrobial therapy in terms of PD reduction. However, the need to use antibiotics in association with SRP must be considered carefully; any systemic protection provided by antibiotics and the small gain in clinical PD status must weighed against the known risks of enhancing the development of antibiotic resistance and other side effects when considering the use of antibiotics in conjunction with SRP in diabetic subjects. The clinical significance of these improvements is questionable and should be further investigated.

Comments

While the studies included in this review were considered to be at low risk of bias they were small the largest only including 38 patients. A majority of the studies (10) used doxycycline although a range of dosages were employed. Overall use of antibiotics only demonstrated a statistically significant benefit for improved one of the periodontal parameter investigated, probing depth. However, with was only 0.15mm and is of questionable clinical relevance and given the growing concerns regarding antibiotic resistance routine use in this or any population should be questioned.

Links

Primary paper

Grellmann AP, Sfreddo CS, Maier J, Lenzi TL, Zanatta FB. Systemic antimicrobials adjuvant to periodontal therapy in diabetic subjects: a meta-analysis. J Clin Periodontol. 2016 Mar;43(3):250-60. doi: 10.1111/jcpe.12514. Review. PubMed PMID: 26790108.

Other references

Non-surgical periodontal treatment – is there a role for systemic antibiotics?