Aggressive periodontitis and systemic antibiotics

Aggressive periodontitis (AgP) tends to affect younger patients (<30) and is considered not to respond well to scaling and root planing (SRP) and number of reviews have suggested a benefit with adjunctive antibiotic for patients with AgP.

The aim of this review was to assess the effect of adjunctive systemic antibiotics in the treatment of AgP. The specific aim of this study was to assess whether the combinations of SRP and different antibiotics would lead to better outcomes in terms of reducing probing depth (PD) or gaining clinical attachment level (CAL) in comparison with SRP alone.

Methods

Searches were conducted in the Medline, Embase, CENTRAL (Cochrane Central Register of Controlled Trials) and OpenGray databases. Randomised controlled trials (RCTs) in patients with AgP comparing scaling and root planing (SRP) alone with SRP plus a single antibiotic or a combination of drugs with a minimum of 3 months follow up were considered.

Study selection and data abstractions were carried out independently by two reviewers. Quality assessment of studies was undertaken using the Cochrane risk of bias tool. Network meta-analysis was undertaken using the Bayesian random-effects hierarchical models using WinBUGS software. Conventional random-effects pairwise meta-analysis were also undertaken with pooled outcomes expressed as weighted mean differences (WMD) with their associated 95% confidence intervals (CI).

Results

14 papers reporting 11 studies involving a total of 418 patients were included.
2 studies were considered to be at low risk of bias 7, unclear and 2 high risk of bias.
9 of the trials found improved outcomes with systemic antibiotics.
8 pairwise meta-analysis for changes in mean full-mouth clinical attachment level (CAL) and probing depth (PD) were conducted:
- For SRP + azithromycin (Azi) versus SRP + Placebo, the outcomes indicated a statistically significant greater gain in mean full-mouth CAL (WMD: 0.51 mm [95% CI: 0.06, 0.96]; (p=0.03; I2 =77%) but difference in mean full- mouth PD reduction between groups was not statistically significant.
- For SRP + doxycycline (Dox) versus SRP, there were no significant differences in CAL gain and reduction in PD between groups.
- For SRP + metronidazole (Mtz)/ versus SRP, pooled estimates showed a statistically significant greater gain in CAL (WMD: 1.08 mm [95% CI: 0.54, 1.62]; p < 0.0001; I2 = 0%) and reduction in PD (WMD: 1.05 mm [95% CI: 0.62, 1.48]; p < 0.00001; I2 = 0%) for patients treated with SRP + Mtz.
- Similarly, the studies assessing SRP + Mtz/ amoxicillin (Amx)  versus SRP or SRP + Placebo showed a statistically significant greater CAL gain (WMD: 0.45 mm [95% CI: 0.33, 0.56]; p < 0.00001; I2 = 0%) and reduction in PD (WMD: 0.53 mm [95% CI: 0.45, 0.61]; p < 0.00001; I2 = 0%) for the SRP + Mtz/Amx groups.
5 studies contributed to the network meta-analysis:
- For CAL gain:- SRP + Mtz was most likely (almost 90%) to be categorized the best amongst all four treatments, followed by SRP + Mtz/ Amx, SRP + Dox and SRP alone.
- For PD reduction: – SRP + Mtz was most likely (>95%) to be categorized the best amongst all four systemic antibiotic protocols followed SRP + Mtz/ Amx, SRP + Dox and SRP alone.

Conclusions

The authors concluded: –

The results of these analyses support a statistically significant benefit of adjunctive systemic antibiotics in the treatment of AgP. The most consistent advantages – reduction in PD and CAL gain – were attained with the use of Mtz and Mtz + Amx. Future RCTs should be designed in order to directly compare these two antibiotic protocols in the treatment of AgP.

Comments

A search of 3 major databases has been conducted for this review and only 11 small studies involving a total of 418 patients could be included. Only 2 of the studies were considered to be at low risk of bias larger due to the non-reporting of the method of randomisation. The overall finding of a small additional benefit over SRP with adjunctive antibiotics is in line with earlier systematic reviews (see links). The limited quality of the studies means that the results should be interpreted with caution and the growing problem of antibiotic resistance also needs to be taken into consideration.