Adjunctive antibiotics in the treatment of generalized aggressive periodontitis

Abstract

Can an adjunctive course of metronidazole and amoxicillin improve out-comes in people who have generalised aggressive periodontitis? Guerrero A, Griffiths GS, Nibali L, Suvan J, Moles DR, Laurell L, Tonetti MS. Adjunctive benefits of systemic amoxicillin and metronidazole in non-surgical treatment of generalized aggressive periodontitis: a randomized placebo-controlled clinical trial. J Clin Periodontol 2005; 32:1096–1107. Design The study was a randomised controlled trial. Intervention People who had generalised aggressive periodontitis (GAP) underwent a standard cycle of periodontal therapy (oral hygiene instruction, supra-and subgingival mechanical instrumentation of root surface) following which members of the test group took an adjunc-tive course of systemic antibiotics (500 mg metronidazole and 500 mg amoxicillin) for 7 days and the control group received a placebo. Reassessment visits occurred 2 and 6 months post-treatment. Outcome measure The primary outcome measure was probing pocket depth (PPD) reduction in sites with an initial PPD >7 mm. The secondary outcome measure was changes in other clinical parameters. Results A total of 41 subjects took part in the study, with one lost to follow-up between the 2-and 6-month reassessments. In both groups all clinical parameters improved at 2 and 6 months. The test group showed greater reduction in PPD than the control group in terms of full-mouth PPD and life accumulative attachment loss. Seventy-four percent of pockets with PPD >5 mm at baseline were <4 mm at 6 months in the test group compared with 54% in the control group (P=0.008). Conclusions A 7-day adjunctive course of metronidazole and amoxi-cillin improved short-term clinical outcomes in people who had GAP. Commentary Although GAP affects a small proportion of the general of the popu-lation, it is a disease of high morbidity. Formerly known as gener-alised juvenile periodontitis, GAP generally affects younger adults who otherwise appear healthy, and the most distinguishing feature is the rapid rate of attachment loss. This destruction tends to occur episodically, affecting several areas of the mouth, and tends also to have a familial aggregation. There is commonly a higher rate of cases refractory to treatment than in those of chronic periodontitis, prob-ably because of the high prevalence of Actinobacillus actinomyce-temcomitans and other virulent pathogens. Guerrero and colleagues' RCT examines the effect of full-mouth periodontal debridement completed within 24 h, followed by a 0.2% chlorhexidine rinse twice daily for 2 weeks post-treatment. (This approach was first documented by Quirnyen et al., 1 but does not appear to be repeated by other groups. Nonetheless, it seems to be a reasonable method.) This was followed by 500 mg each of the antibi-otics metronidazole and amoxicillin, three times daily for 7 days. This is a well-designed study, with blinded randomisation, placebo controls and intent-to-treat analysis. The groups were stratified for two significant confounding variables, smoking and baseline PPD. What is most unique about this study, however, is its analysis of the data. Most periodontal clinical trials report mean changes in full