ORAL HEALTH EVIDENCE-BASED PRACTICE PROGRAM
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Title Adjunct Use of Systemic Azithromycin with Scaling and Root Planing in Treatment of Chronic Periodontitis Results in Only Limited Gain in Clinical Attachment Level and Limited Probing Depth Reduction
Clinical Question In a patient with chronic periodontitis, how does adjunct systemic azithromycin in conjunction with scaling and root planing versus scaling and root planing alone compare in terms of periodontal outcomes including probing depths and clinical attachment levels?
Clinical Bottom Line Systemic use of azithromycin in chronic periodontitis patients has only limited benefits in terms of clinical attachment level gains and probing depth reduction based on several recent large meta-analyses.
Best Evidence (you may view more info by clicking on the PubMed ID link)
PubMed ID Author / Year Patient Group Study type
(level of evidence)
#1) 25142259Keestra/2015209 chronic periodontitis patients in 6 studiesMeta-Analysis
Key resultsFor moderate (4-6 mm) pocket depths, adjunctive azithromycin showed no significant improvement over SRP. For deep (>6 mm) pocket depths, adjunct azithromycin results in a reduction of 0.52 mm ± 0.28 mm at 3 months and 0.52 mm ± 0.34mm at 6 months, but no significant difference was seen at 12 months. For gain in CAL, adjunctive azithromycin showed no significant improvement over SRP alone at all time periods and for all pocket depths, with the exception of deep (>6 mm) pockets at 3 months (WMD = 0.43 mm ± 0.40 mm).
#2) 26113099Smiley/2015239 chronic periodontitis patients in 7 studiesMeta-Analysis
Key resultsClinical attachment gain for adjunctive azithromycin was 0.29 mm (95% CI, 0.11-0.47).
#3) 25726342Garcia Canas/2015335 chronic periodontitis patients in 9 studiesSystematic review of randomized trials
Key resultsFor adjunctive azithromycin in the nine studies analyzed, four showed statistically significant gain in attachment, ranging from 0.01 mm to 1.15 mm. However, five studies showed that there was no statistically significant gain in attachment. Four studies showed a statistically significant difference in probing depth reduction ranging from 0.21 mm to 1.03 mm. However, five studies showed that there was no statistically significant probing depth reduction.
Evidence Search ("Anti-Bacterial Agents"[Mesh]) AND "Chronic Periodontitis"[Mesh] Pub med clinical queries: “systemic antibiotics in the treatment of chronic periodontitis.” systemic[All Fields] AND ("anti-bacterial agents"[Pharmacological Action] OR "anti-bacterial agents"[MeSH Terms] OR ("anti-bacterial"[All Fields] AND "agents"[All Fields]) OR "anti-bacterial agents"[All Fields] OR "antibiotics"[All Fields]) AND ("chronic periodontitis"[MeSH Terms] OR ("chronic"[All Fields] AND "periodontitis"[All Fields]) OR "chronic periodontitis"[All Fields]) AND ("azithromycin"[MeSH Terms] OR "azithromycin"[All Fields])
Comments on
The Evidence
Validity: Keestra 2015 and Smiley 2015, two systemic reviews and meta-analyses, along with Garcia 2015, a systematic review, all reviewed the available literature for potential risk of bias and validity. All three evaluated only randomized controlled trials and provided their search methodology for findings relevant articles. All three articles evaluated the risk of bias of each individual study included. These three studies evaluated anywhere from six to nine studies that included 209 to 335 patients. Keestra 2015 and Smiley 2015 both included a meta-analysis while Garcia 2015 did not. The Keestra study found little to no benefit in attachment levels and only slight benefit in pocket depth reduction. The Smiley study showed a statistically significant but clinically insignificant gain in attachment levels. The Garcia review found mixed results depending on the randomized controlled trial considered for both attachment level and pocket depth reduction. Perspective: While some studies show that there may be a small benefit for adjunct azithromycin, additional factors must be considered. Prevalence of chronic periodontitis is high, and therefore widespread administration of antibiotics could greatly increase the prevalence of antibiotic resistance for only a limited statistical and clinical gain in attachment levels and pocket depth reduction.
Applicability On average, clinical attachment levels and probing depth reduction were not improved significantly in the population of chronic periodontitis patients studied. However, one must consider that the patient in the dental chair is never an average patient and therefore the decision of using adjunct azithromycin may depend more heavily on other factors such as estimated host resistance, patient co-morbidities and initial disease presentation. One must also consider the potential for adverse drug reactions. Ultimately these factors must all be weighed when making the decision to use or not adjunctive systemic azithromycin.
Specialty/Discipline (General Dentistry) (Periodontics)
Keywords Chronic Periodontitis, Systemic Antimicrobials, Azithromycin, Clinical Attachment Level
ID# 3102
Date of submission: 11/08/2016spacer
E-mail penner@uthscsa.edu
Author Jeffrey Penner, DDS
Co-author(s)
Co-author(s) e-mail
Faculty mentor/Co-author Guy Huynh-Ba, DDS, MS
Faculty mentor/Co-author e-mail HuynhBa@uthscsa.edu
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