04.09.2011
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Diabetes mellitus is a risk factor for gingivitis and periodontitis. Diabetic adults with poorly controlled glycemia had a 2.9-fold increased risk of having periodontitis compared with nondiabetic adult subjects.1 2 It is estimated that periodontitis affects 740 million people worldwide.2 , 3 The link between both pathologies is an altered immunoinflammatory response and changes in gingival microflora as a consequence of chronic hyperglycemia. This pathogenic flora has a relationship with worsened periodontitis. The complications of chronic periodontitis are the progressive destruction of the periodontal ligament and alveolar bone.4–7 Standard periodontal treatment includes mechanical debridement to remove biofilm and calculus from the affected root surfaces.8 9 Because this procedure has some limitations, the use of antimicrobial agents is an option to eradicate pathogenic bacteria in deep pockets, root furcations, and concavities. In this sense, the objective of periodontal antibiotic therapy is to reduce the number of periodontal pathogens and produce a healthy periodontium in a short time.10 11 The most used treatment is the combination of amoxicillin with metronidazole (AMX-MET) due their synergistic effect and their wide spectrum of activity.12 However, there are reports of higher resistance in some pathogens compared with other antibiotics. Rams et al , mentioned a resistance of 55% vs 30.3% with the use of AMX-MET compared with clindamycin, respectively.13 Clindamycin is a semisynthetic derivative of lincomycin, used in the treatment of dental, bone or joint infections. Moreover, it has been used in the treatment of foot infections in patients with diabetes and in the prevention of endocarditis.14–16. In spite of both antibiotic regimens being effective against anaerobic microorganisms, there are no studies that compare both therapies in the treatment of periodontitis in patients with diabetes. The purpose of the present study was to determine the efficacy of systemic clindamycin compared with amoxicillin/metronidazole in the treatment of periodontitis during nonsurgical periodontal treatment in patients with type 2 diabetes. A parallel, randomized, double-blind, single-center clinical trial was designed to compare the efficacy of two antibiotic therapies. The study was carried out on patients at the Integral Dentistry Clinics of the University Center of Health Sciences of the University of Guadalajara in Jalisco, Mexico. The participants attended for dental care from August 2015 to December 2016. The study protocol was approved by the ethical committee of the Universitary Center of Health Sciences of University of Guadalajara and conducted according to Good Clinical Practice and the principles of the Declaration of Helsinki. All patients provided written informed consent before the initiation of study procedures. The protocol was registered in Clinicaltrials.gov NCT 03374176. The sample size was calculated with a 95% confidence level and statistical power of 80%. A SD of 1.0 mm with an expected difference of 1.0 mm probing depth reduction between treatments. This resulted in a total of 14 patients per arm; however, considering an attrition of about 20%, it was established that least 21 subjects should be included in each treatment group. Download figure Open in new tab Download powerpoint. Download figure Open in new tab Download powerpoint. Download figure Open in new tab Download powerpoint. Comparison between groups in final clinical assessments. Basal demographics characteristics and clinical parameters of study groups. No loss of teeth between groups compared with baseline was reported. No serious adverse events occurred during the study. Complications due to diabetes have negative effects on different aspects of patients’ health: economics, quality of life, and self-esteem. Periodontitis is a common complication in patients with diabetes, not frequently mentioned. Poor glycemic control associated with periodontitis can modify the connective tissues response and the progressive destruction of periodontal structures. Periodontal treatment may have a positive effect on hyperglycemia, independently of diabetic treatment.17–19. Recent evidence has shown that the use of adjunct systemic antibiotics with SRP in patients with diabetes is inconclusive.10–12 Santos et al , in a systematic review, evaluated the effect of different antibiotics on periodontal parameters in patients with diabetes. The results showed a positive significant effect with the use of SRP plus antibiotics, reducing the probing depth and bleeding in probing.20 Our results showed a similar reduction in both parameters with the use of clindamycin or amoxicillin-metronidazole. In addition, these findings are in concordance to other randomized clinical trials that had used systemic antibiotics in similar populations.21–25. Several authors refer to SRP plus amoxicillin-metronidazole as the most effective therapy for periodontitis in patients with diabetes when compared with several antibiotics.26–29 However, no studies compare AMX-MET with clindamycin. Clindamycin is a broad-spectrum antibiotic, active against aerobic and anaerobic bacteria including coverage against beta-lactamase producing pathogens. It could be considered an option in the treatment of diabetic infections in different sites.30. Unlike other studies, the present trial shows that clinical benefit can be achieved with 7 days of antibiotic treatment vs the 14 days prescribed by other authors.31 According to a rational use of antibiotics, the duration of treatment should be the shortest possible and most acute oral infections are resolved in less than 7 days.32 Moreover, the use of short courses have some advantages: fewer adverse events, more adhesion, lower costs, and so on.32 There is a tendency to use higher doses for a shorter time, but the evidence about this practice is not conclusive.33 We consider a better option is to use standard doses for a shorter time as complement to periodontitis treatment. The intragroup significant differences between baseline and the final visit were observed in both groups. The efficacy of amoxicillin and metronidazole in the treatment of periodontitis is established evidence. However, the use of clindamycin is a new option in oral infections. In addition, in the present study, no teeth were reported to have been lost in either group. The principal limitation of the present study was the absence of a group with SRP plus placebo. This study design, using a placebo group, could help us to evaluate the efficacy of clindamycin versus SRP alone. However, this study shows that clindamycin is a new option similar to AMX-MET for periodontitis treatment in patients with diabetes. The administration during 7 days of clindamycin or amoxicillin/metronidazole showed the same efficacy for reducing probing depth, plaque index, and bleeding on probing in patients with periodontitis and type 2 diabetes. We appreciate the comments and correction style of Paul Riordan of Write 2 Publish. We also appreciate the comments and support of Raul Baptista Rosas and Luis Cortes of Research Department of CUTonala. Comparison of adjunctive azithromycin and amoxicillin/metronidazole for patients with chronic periodontitis: preliminary randomized control trial. Oral Health Centre of Western Australia, Nedlands, Western Australia, Australia. Associate Professor and Head of Periodontology Department. Oral Health Centre of Western Australia, Australia. Princess Margaret Hospital, Subiaco, Western Australia, Australia. Centre for Applied Statistics, School of Mathematics and Statistics, The University of Western Australia, Western Australia, Australia. Oral Health Centre of Western Australia, Nedlands, Western Australia, Australia. Associate Professor and Head of Periodontology Department. Oral Health Centre of Western Australia, Australia. Princess Margaret Hospital, Subiaco, Western Australia, Australia. Centre for Applied Statistics, School of Mathematics and Statistics, The University of Western Australia, Western Australia, Australia. There are insufficient guidelines for the use of adjunctive systemic antibiotics for patients with periodontal disease. The aim of this study was to compare clinical outcomes for patients with moderate?advanced chronic periodontitis treated with: scaling and root planing (SRP), SRP with amoxicillin and metronidazole (A+M), SRP with Azithromycin (Az). Thirty?seven non?smokers with generalized moderate to advanced chronic periodontitis were divided into three treatment groups: SRP, A+M and Az. Patients received the medications after the last SRP session and were reviewed three months later. Changes in clinical parameters were compared between the groups. Separate analyses were executed for: ‘all sites’, ‘molar sites’, ‘sites with different PPD severities’ and ‘number of sites with shallow, moderate and deep PPD’. The three groups exhibited improvements in most clinical parameters. At three months, A+M showed a higher reduction in PPD compared to Az in the ‘all sites analysis’. Molars exhibited better reduction in BOP and PPD with A+M than SRP. Pocket depth of the 4–6 mm category reduced more in the A+M than SRP. A+M experienced a higher increase in the number of sites with PPD 1–3 mm than Az. Adjunctive systemic antibiotics in the initial phase of treatment may result in improved clinical outcomes. Chronic periodontitis is an infectious disease resulting in inflammation within the supporting structures of teeth, progressive attachment loss and bone loss. 1 It results from an imbalance between the microorganisms in the plaque biofilm, the host response and modifying factors. 2 The goals of treatment of periodontal disease are to resolve the inflammation and to create a clinical condition compatible with periodontal health. 3 Scaling and root planing (SRP) remains to the standard treatment of chronic periodontitis. 4, 5 However, SRP is not always sufficient in producing satisfactory periodontal clinical outcomes such as pocket depth reduction and gain of clinical attachment levels. In such cases, adjunctive treatment may be required. Such adjuncts include: (1) the use of locally administered antimicrobial agents; (2) the use of systemic antibiotics; and (3) surgical procedures. This study assessed the usefulness of systemic antibiotics (AB) as an adjunct to the initial phase of periodontal treatment. The use of adjunctive systemic antibiotics in the treatment of periodontal disease has been a topic of interest since the 1980s. The clinical and microbiological effects of different types of systemic antibiotics (AB) such as tetracycline, 6, 7 amoxicillin, 8 metronidazole, 9, 10 clindamycin, 11 azithromycin, 12-15 and combinations 16-18 have been tested on different forms of periodontal diseases including localized and generalized aggressive periodontitis, 19, 20 chronic periodontitis 6, 9, 13 and refractory periodontitis. 8, 21 Such extensive studies have resulted in prolific literature with a vast variability in study designs, results and take?home messages. Systematic reviews demonstrated that the use of adjunctive systemic antimicrobials in combination with SRP resulted in more gain in clinical attachment levels (CAL), more reduction in periodontal probing depth (PPD) and reduced risk for additional loss of attachment. 22-24 Such improvements were consistent for both chronic as well as aggressive periodontitis. 23 The literature generally agrees that if systemic AB are to be used, they should only be in conjunction with thorough mechanical periodontal debridement and not as a monotherapy. 24 Despite that, there is a lack of evidence based guidelines for their use in periodontitis patients. Questions that remain unsolved relate to: (1) patient selection; (2) choice of antibiotics; (3) dosage of medication; and (4) timing of administration. Amoxicillin and metronidazole (A+M) Numerous randomized controlled studies have tested the efficacy of A+M in chronic periodontitis (CP) and for aggressive periodontitis (AP) patients.
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After exposure for penicillin-susceptible recommended dose of amoxicillin provides the most likely explanation for the positive relationship found between increasing wealth and increasing antibiotic consumption in LMICs. Don’t help can begin immediately notation.
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| | 15.11.2011 - KURTOY_PAREN |
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