Systemic antibiotics for aggressive periodontitis?

Aggressive periodontitis is usually associated with onset at an early age (around 25 years of age) and is characterised by a rapid loss of clinical attachment and alveolar bone. Treatment and maintenance can be challenging and non-surgical periodontal treatment is normally a first stage and systemic antibiotics have used as an adjunct.

The aim of this review was to evaluate the effectiveness of different systemic antibiotics in combination with scaling and root planing (SRP) compared to SRP alone in patients with untreated aggressive periodontitis.

Methods

Searches were conducted in the Medline/PubMed database and supplemented with a manual search of issues from the past 10 years of the Journal of Clinical Periodontology, Journal of Periodontal Research and Journal of Periodontology. Randomised controlled trials (RCTs) in patients with aggressive periodontitis with follow up period of 1 month or longer were included. Only English language papers were considered. Two reviewers independently selected studies and abstracted data. Study quality was assessed. Extracted data were pooled using a random effect model. Weighted mean differences were calculated and heterogeneity was assessed. Primary outcomes were probing pocket depth (PPD) reduction and clinical attachment level change.

Results

13 studies published in 14 articles were included.
8 studies were considered to be at low risk of bias, 2 at moderate risk and 4 at high risk.
Systemic antibiotics showed statistically significant difference in pocket depth and clinical attachment levels

Overall	Studies	Patients	PPD Mean difference ( SD)	Clinical attachment level Mean difference (SD)
3 months	13	386	0.34 ± 0.11 mm	0.40 ± 0.30 mm
6 months	10	290	0.51± 0.11 mm	0.36 ± 0.10 mm
12 months	2	65	0.51 ± 0.38 mm	0.46 ± 0.37 mm

Moderate pockets	Studies	PPD Mean difference (SD)	Clinical attachment level Mean difference (SD)
3 months	6	0.36 ± 0.22 mm	0.26 ± 0.18 mm
6 months	6	0.42 ± 0.22 mm	0.52 ± 0.12 mm
12 months	2	0.65 ± 0.94 mm	0.83 ± 0.38 mm

Deep pockets	Studies	PPD Mean difference ( SD)	Clinical attachment level Mean difference (SD)
3 months	6	0.74 ± 0.36 mm	0.59 ± 0.18 mm
6 months	6	0.85 ± 0.55 mm	0.96 ± 0.21 mm
12 months	2	1.26 ± 0.81 mm	1.00 ± 0.80 mm

Conclusions

The authors concluded:

For the treatment of patients with aggressive periodontitis, systemic antibiotics combined with non-surgical periodontal therapy resulted in a significant additional effect compared to non-surgical therapy alone. There is a visible trend that showed metronidazole + amoxicillin is the most potent antibiotic combination.

Comments

This review has restricted its search to a single database a number of relevant journals and to those studies published in English so it is possible that some relevant studies have been missed. Earlier this year we blogged about another review of this question (Dental Elf – 20^th Jul 2015), that review searched a broader range of databases focusing on periodontal outcomes at 6 months and including 11 studies. Only 8 of the studies included in that review were included in this current review by Keestra et al.

Both of these reviews demonstrate statistically significant benefits with the use of systemic antibiotics further suggesting that that metronidazole and amoxicillin appears to be the most effective of the antibiotics. However, the available studies use a number of different antibiotics and dosages and the quality of the available studies is not high. The reporting of adverse effects from antibiotic usage is limited. With mounting concerns over antibiotic resistance the likely clinical benefit of systemic antibiotic usage over non-surgical treatment alone needs to be taken into consideration and the authors of the review note that,

Their prescription, however, should be considered on a case-by- case basis and limited as much as possible, considering the risks of indiscriminate use of systemic antibiotics in the world.