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40, 58-60 Long?term studies also indicated more pocket reduction on non?molars than molars. 61, 62 Hence, in this study a separate analysis was conducted to investigate whether the use of adjunctive antibiotics may amoxicillin potassium clavulanate tablets have an additional benefit on molar teeth. Between the two time points, significant improvement in attachment levels was only observed in the A+M and Az groups but not in the SRP group. Gain in CAL in the A+M and the Az groups were 0.70 mm and 0.43 mm respectively. The modest gain in CAL in the SRP group was 0.22 mm. When a comparison between the groups was conducted, A+M seemed to be superior to SRP in the reduction of molar bleeding score and the reduction in PPD. 17 also showed that molars benefited significantly more from the antibiotics than non?molars in a three?month study. Four per cent molar sites remained with PPD >4 mm and BOP in the A+M group as opposed to 10.3% in the placebo group. The treatment outcome for this study was the number of persistent PPD and not the change in other clinical parameters (BOP, PPD and CAL). Therefore, a direct comparison between the current study and the Mombelli et al . It should be noted that the mean PPD at baseline for the three groups was low (3.98 mm for SRP, 3.94 mm for A+M and 3.51 mm for Az). This is a major disadvantage of using means of all sites added up together. Mean full?mouth PPD and CAL values may not be the best way to describe the data. Shallow sites, which are not expected to change with therapy, are likely to dilute the changes observed at the deeper sites, which are the sites of therapeutic concern. For this reason, a further analysis was done by categorizing the PPD into shallow, moderate and deep. All three treatment groups also showed a significant reduction in PPD and gain in CAL for the initially moderate (PPD 4–6 mm) and deep (>6 mm) PPD. It was also clear that the clinical improvement is more obvious in the deeper sites. For example, in the 4–6 mm PPD category, the reduction in mean PPD was 1.08 mm, 1.47 mm and 1.16 mm for the SRP, A+M and Az groups respectively). For the >6 mm category, this reduction was 2.37 mm, 2.64 mm and 2.53 mm for the SRP, A+M and Az groups respectively. A similar observation was noted in the gain in CAL, where deep sites showed more gain in CAL compared to moderate sites. In the 4–6 mm PPD category, the mean gain in CAL was 0.68 mm for the SRP group, 0.94 mm for the A+M group and 0.71 mm for the Az groups. In the deep PPD category (>6 mm) the mean gain in CAL was 1.59 mm for the SRP group, 1.81 mm for the A+M group and 1.35 mm for the Az group. This is in agreement with studies that show that deeper sites tend to show more clinical improvement after SRP. 4, 5, 63 The changes that occurred in the clinical parameters of the SRP group are also in agreement with studies that estimated those changes in non?surgical treatment alone. 57, 64 Sites with 4–6 mm PPD show an average reduction of 1–2 mm in probing depth and a gain in CAL of 0–1 mm. Sites with initial PPD >6 mm show a reduction of 2 mm PPD and 1–2 mm CAL gain. Comparing between the groups, A+M also showed a superior reduction in PPD compared to the SRP group only for the 4–6 mm category (1.47 mm vs 1.08 mm). The reduction in PPD for the initially >6 mm category did not demonstrate a difference between the three groups. Again, this lack of difference could be related to the small sample size included in this study. The beneficial effect of A+M in moderate and deep sites was demonstrated in other clinical studies. In a three?month trial, 48 subjects receiving A+M exhibited a greater mean CAL gain, reduction in PPD in intermediate and deep sites and a lower percentage of sites with PPD ?5 mm at three months, in comparison with those treated with SRP only. A+M was also the only treatment that significantly reduced the levels and proportions of all red complex pathogens and elicited a significantly greater beneficial change in the microbial profile in comparison with SRP only. In a one?year study, patients were randomized to receive SRP only, SRP with metronidazole or SRP with A+M. The use of the antibiotics showed superiority in reducing the mean PPD and mean gain of attachment, which was more evident in the intermediate and deep sites. Despite the lack of significant differences between the two antibiotic groups, an overall greater clinical benefit was observed in the A+M more than metronidazole. 49 One systematic review compared the effect of different antibiotics on initially moderate and deep sites. 65 The analysis showed for initially moderate and deep pockets, A+M resulted in clinical improvements that were more pronounced over azithromycin. Traditionally, RCTs have used changes in means PPD and CAL to evaluate treatment outcomes. However, the use of these parameters in defining treatment efficacy has been questioned in numerous studies. Instead, it is the presence or absence of persistent pockets that was suggested to be a more clinically significant outcome. Well conducted studies clearly showed that the presence of residual pockets after treatment, especially those with PPD ?5 mm buy amoxicillin 500mg dosage represent incomplete treatment and are important risk indicators for recurrence of periodontal disease in patients under long?term periodontal maintenance. 66, 67 Residual pockets are also an important part of the periodontal risk assessment suggested by Lang and Tonetti. 3 Therefore, it has been suggested to use the mean number (or percentage) of sites deep PPD as an outcome of treatment success. In the current study, all three treatment groups showed a significant increase in the shallow sites (1–3 mm) from baseline to three months. All three treatment groups also had a reduction in the number of sites with PPD 4–6 mm. As for the deep sites (PPD >6 mm), the two antibiotic groups but not the SRP group showed a significant reduction in number of those sites. These results suggest that adjunctive antibiotics may be more beneficial in patients with a generalized distribution of deep PPD. After three months, the SRP group had a mean of 5.6 deep sites while the A+B and Az groups had a mean of 1.6 and 1.8 deep sites, respectively. The number of sites >6 mm were around 3.5 times greater in the SRP group compared to the two antibiotics groups at three months.
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