How effective is metronidazole as an adjunct to scaling and root planing in the treatment of chronic periodontitis? A systematic review
This summary is based on the article published in the Journal of Periodontal Research: Effectiveness of metronidazole as an adjunct to scaling and root planing in the treatment of chronic periodontitis: a systematic review and meta-analysis (February 2014)
Sgolastra, M. Severino, A. Petrucci, R. Gatto, and A. Monaco
Context
- Modern periodontal treatment generally aims to eliminate sub-gingival biofilms and to remove microbial deposits from the root surfaces, thereby reducing tissue destruction, controlling etiologic agents and restoring a subgingival microflora that is compatible with periodontal health (1, 2).
- Scaling and root planing (SRP) is the most common periodontal treatment. (3) However, SRP has several limitations, such as difficulties in accessing deep pockets, furcations and concavities. (4, 5) and an inability to eliminate microbial pathogens located in dentin tubules, lacunae and concavities. (6)
- To overcome these limitations, researchers have suggested several protocols, including systemic antimicrobial administration.
- Metronidazole (MET) has been suggested as an adjunct to scaling and root planing (SRP) in the treatment of chronic periodontitis. However, its clinical effectiveness and effects on periodontal pathogens remain to be defined.
Purpose of the Review
- To review the scientific literature to ascertain the effect of MET as an adjunctive therapy to SRP as compared to SRP alone.
- To assess the clinical safety of MET administration.
Key Findings
Although based on a limited number of studies, the adjunctive use of MET to SRP may provide additional clinical benefits compared to SRP alone.
References
- Kepic TJ, O’Leary TJ, Kafrawy AH. Total calculus removal: an attainable objective. J Periodontol 1990; 61: 16–20.
- Hinrichs JE, Wolff LP, Pihistrom B, Schaffer EM, Liljemark WE, Bandt CL. Effects of scaling and root planing on subgingival microbial proportions standardized in terms of their naturally occurring distribution. J Periodontol 1985; 56: 187–194.
- Carvalho LH, D’Avila GB, Leao A, Haffajee AD, Socransky SS, Feres M. Scaling and root planing, systemic metronidazole and professional plaque removal in the treatment of chronic periodontitis in a Brazilian population: I. Clinical results. J Clin Periodontol 2004; 31:1070–1076.
- Badersten A. Nilve′us R, Egelberg J. Effect of nonsurgical periodontal therapy (VIII). Probing attachment changes related to clinical characteristics. J Clin Periodontol 1987; 14: 425–432.
- Rabbani GM, Ash MM Jr, Caffesse RG. The effectiveness of subgingival scaling and root planing in calculus removal. J Periodontol 1981; 52: 119–123.
- Mombelli A, Cionca N, Almaghlouth A. Does adjunctive antimicrobial therapy reduce the perceived need for periodontal surgery? Periodontol 2000 2011; 55: 205–216.
Do you have any particular question on this topic? Do you have any comments or suggestions? Email us at oasisdiscussions@cda-adc.ca
You are invited to comment on this post and provide further insights by posting in the comment box which you will find by clicking on “Post a reply” below. You are welcome to remain anonymous and your email address will not be posted.
I was wonder what dosages that the study was using and for what time period?
What were they basing success on?
Thank you
What dose and course of metronidazole were recommended?
I used 250 MG three times daily for one week.
RESULTS:
After the study selection process, six randomized clinical trials were included in the meta-analysis. The results of the meta-analysis indicated that SRP + MET provided additional benefits when compared to SRP alone in terms of probing depth reduction (MD, 0.18; 95% CI, 0.09-0.28; p < 0.05) and clinical attachment level gain (MD, 0.10; 95% CI, 0.08-0.12; p < 0.05). No evidence of heterogeneity was detected.
CONCLUSION:
The meta-analysis results seem to support the effectiveness of adjunctive MET with SRP compared to SRP alone. However, given the low number of included studies and limitations of meta-analysis, future studies are needed to confirm these results
Taken from http://www.ncbi.nlm.nih.gov/pubmed/23668676
http://onlinelibrary.wiley.com/doi/10.1111/jre.12089/pdf
My interpretation of this is that although we see a reduction it is hardly something that could be measurable and quantifiable in a clinical setting. Given the studies were able to achieve statistical significance and detect a difference doesn't mean (in my opinion) that it is real world clinical significance. Being able to see a difference of 1/5th-1/10th of a mm is not worth the risk that antibiotics themselves carry to the individual, or to the population as a whole from Abx over use. Some of these regimens at TID 14d… It also has to be asked whether there is a significant lasting effect of such treatment adjuncts in the interim between re-care visits.
On behalf of Dr. James Hennessy:
It has been my experience over many cases that metranidazole at the dosage level of 250 mg b.i.d in conjunction with amoxicillin (500 mg q8h) for 7 days has a tremendous affect in the treatment of periodontitis.
An even better combination is metranidazole with spiramycin (don’t recall the dosage level since this drug is not usually available at most pharmacies so I haven’t been able to use it for quite some time); especially in the treatment of ANUG. I recall reading a study which was conducted in the late 1970’s which indicated that these two drugs had a synergistic effect on each other in the treatment of perio disease.
JCDA Oasis Team
I agree that metronidazole has a place in therapy for certain periodontal conditions; however, the objective of Sgolastra’s review was specific for the chronic periodontitis.
I totally agree with Andrew that despite of the statistical significance, the clinical significance of the reported difference is very questionable.