J Clin Periodontol 2005; 32: 1096–1107 doi: 10.1111/j.1600-051X.2005.00814.x Copyright r Blackwell Munksgaard 2005

Adrian Guerrero1,2, Gareth S. Griffiths1, Luigi Nibali1, Jean Suvan1, Adjunctive benefits of systemic 1 1 David R. Moles , Lars Laurell and Maurizio S. Tonetti1 amoxicillin and metronidazole in 1Department of Periodontology and Eastman Clinical Investigation Centre, Eastman Dental Institute and Hospital, University College non-surgical treatment of London, London, UK; 2Private Periodontal Practice, Malaga, Spain generalized aggressive periodontitis: a randomized placebo-controlled clinical trial

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. doi: 10.1111/j.1600-051X. 2005.00814.x. r Blackwell Munksgaard 2005.

Abstract Background: The objective of this study was to assess the adjunctive clinical effect of the administration of systemic amoxicillin and metronidazole in the non-surgical treatment of generalized aggressive periodontitis (GAP). Methods: Forty-one systemically healthy subjects with GAP were included in this 6-month double-blind, placebo-controlled, randomized clinical trial. Patients received a course of full-mouth non-surgical periodontal treatment delivered over a 24 h period using machine-driven and hand instruments. Test subjects received an adjunctive course of systemic antibiotic consisting of 500 mg amoxicillin and 500 mg metronidazole three times a day for 7 days. Clinical parameters were collected at baseline, and at 2 and 6 months post-treatment. Results: In both the test and the placebo groups, all clinical parameters improved at 2 and 6 months. In deep pockets (X7 mm), the test treatment resulted in an additional 1.4 mm (95% confidence interval 0.8, 2.0 mm) in full-mouth probing pocket depth (PPD) reduction and 1 mm (0.7, 1.3 mm) of life cumulative attachment loss (LCAL) gain at 6 months. In moderate pockets (4–6 mm), the adjunctive benefit was smaller in magnitude: PPD reduction was 0.4 mm (0.1, 0.7 mm) and LCAL gain was 0.5 mm (0.2, 0.8 mm). In addition, the 6-month data showed LCAL gains X2 mm at 25% of sites in test patients compared with 16% in placebo (p 5 0.028). Similarly, PPD reductions of 2 mm or more were observed in 30% of sites in test and 21% of sites in placebo patients. Seventy-four percent of pockets with PPD X5 mm at baseline were 4 mm or shallower at 6 months in the test group. This compared with 54% in the placebo group (p 5 0.008). Disease progression at 6 months was observed at 1.5% of test and 3.3% of sites in test and placebo, respectively (p 5 0.072). Key words: antibiotics; generalized aggressive periodontitis; human; randomized-controlled Conclusions: These data indicate that a 7-day adjunctive course of systemic clinical trial; treatment metronidazole and amoxicillin significantly improved the short-term clinical outcomes of full-mouth non-surgical periodontal debridement in subjects with GAP. Accepted for publication 1 June 2005

1096 Treatment of generalized aggressive periodontitis 1097

Generalized aggressive periodontitis the benefits achieved could not be con- performed including a full medical and (GAP) affects a minority of periodontal firmed as attributable to the adjunctive dental history, an intra-oral examination patients but is highly significant because antibiotic. and a full-mouth periodontal probing. it is characterized by severe destruction Recent investigations, performed in A radiographic examination was under- of the supporting apparatus of the teeth, chronic periodontitis patients, have indi- taken using either periapicals or a which may lead to edentulism early in cated that full-mouth scaling and root pantomogram. A periodontal diagnosis life. Because of its relatively rare occur- planing within 24 h (FSR) results in was made, and subjects who fulfilled the rence, few studies have evaluated how to different degrees of clinical and micro- study inclusion/exclusion criteria were treat this condition. The current notion is biological additional benefits (Quirynen provided with a written information that, as with most forms of periodontitis, et al. 1995, Bollen et al. 1996, Vande- sheet, related to the study protocol, and the first step in the treatment of GAP is a kerckhove et al. 1996, Mongardini et al. they were invited to participate in the cause-related treatment phase aimed at 1999, Apatzidou & Kinane 2004). The study. the reduction and/or elimination of the benefits of this approach have not been The study included subjects with (i) pathogenic microflora. systematically evaluated in aggressive GAP (according to the criteria of the In recent years, two approaches have periodontitis patients but initial data in 1999 international classification (Armi- been introduced to improve the clinical chronic periodontitis patients suggest tage 1999); (ii) at least 20 teeth present; outcomes of cause-related periodontal that the full-mouth scaling within 24 h (iii) good general health and (iv) age therapy in chronic periodontitis patients: may perform as well as the conven- between 16 and 35 when first diagnosed the use of adjunctive antibiotics, and tional treatment (Apatzidou & Kinane with aggressive periodontal disease. performing debridement within a 24 h 2004, Kinane 2005, Koshy et al. 2005, Subjects were excluded from the study period, the so-called ‘‘full-mouth disin- Wennstrom et al. 2005). In addition, if they: (i) were considered to have a fection’’ approach (Quirynen et al. 1995). some potential benefits, such as the diagnosis of chronic periodontitis The adjunctive use of systemic anti- application of a better understanding of (according to the criteria of the 1999 biotics is supported by evidence pub- the infectious process, a reduced num- international classification (Armitage lished in systematic reviews of trials ber of treatment sessions for patients, a 1999); (ii) were pregnant or lactating assessing the benefit of systemic anti- more efficient use of treatment time and females; (iii) were females of child- biotics in cases with advanced perio- a reduced cost of therapy, may all be in bearing age not using a standard dontitis (Herrera et al. 2002, Haffajee favour of the FSR (Greenstein 2002). accepted method of birth control; (iv) et al. 2003). Among the possible regi- The aim of this double-blind rando- required antibiotic pre-medication for mens, the combination of amoxicillin mized placebo-controlled study was to the performance of periodontal exami- and metronidazole has gained increasing test the null hypothesis of ‘‘no differ- nation and treatment; (v) suffered from popularity because of its wide spectrum ence in treatment effect of adjunctive any other systemic diseases (cardiovas- of activity and effectiveness in terms of use of systemic amoxicillin plus metro- cular, pulmonary, liver, cerebral, dis- suppression of Actinobacillus actinomy- nidazole during full-mouth non-surgical eases or diabetes); (vi) had received cetemcomitans (Van Winkelhoff et al. cause-related periodontal treatment antibiotic treatment in the previous 3 1989), possibly because of a synergistic (FSR) performed within 24 h compared months; (vii) were taking long-term effect of the combination of amoxicillin with FSR alone, in patients with GAP anti-inflammatory drugs; (viii) had and metronidazole against A. actinomy- patients at 2 and 6 months after the received a course of periodontal treat- cetemcomitans that has been demon- completion of active treatment. ment within the last 6 months; (ix) were strated in vitro (Pavicic et al. 1991, allergic to penicillin or metronidazole; 1994a, b). In addition, chronic perio- and (x) were not able to provide consent dontitis patients harbouring subgingival Material and Methods to participate in the study, or they did Porphyromonas gingivalis benefit sig- Experimental design not accept the proposed treatment plan. nificantly from the combined therapy Informed consent was obtained from all (Winkel et al. 2001). Randomized-con- This study was a randomized placebo- the subjects to be entered in the study. trolled clinical trials have reported clin- controlled, parallel-design, double-blind ical and microbiological improvements clinical trial with 6-month follow-up. Pre-treatment in chronic periodontitis patients treated Ethical approval was obtained from the with these two antibiotics (Berglundh Eastman Dental Institute University All the subjects went through motiva- et al. 1998, Flemmig et al. 1998, Winkel College London Hospitals joint Re- tion sessions during which oral hygiene et al. 2001, Rooney et al. 2002). Further- search and Ethics Committee, and the instructions were given. The purpose of more, some clinical studies have study was conducted according to the these sessions was to ensure that the reported good long-term clinical out- principles outlined in the Declaration of subjects could maintain a proper level of comes in patients with ‘‘severe disease Helsinki on experimentation involving oral hygiene before starting active treat- which was associated with A. actinomy- human subjects. ment, and this was repeated until sub- cetemcomitans’’ (Van Winkelhoff et al. jects showed the ability to maintain 1992, Pavicic et al. 1994a, Winkel et al. good plaque control as evidenced by Population screening 1998) and in aggressive periodontitis pre-treatment plaque scores o20%. (Buchmann et al. 2002) patients when Potential subjects eligible for the study During these sessions, a case presenta- periodontal treatment was completed were identified from the population tion was given to the subject related to with adjunctive use of amoxicillin and referred to the periodontal clinic of the the specific features of his/her disease, metronidazole. However, because of the Eastman Dental Hospital, London. A and a supragingival debridement was lack of a control group in these studies, complete periodontal examination was performed. 1098 Guerrero et al.

Sample size calculation plaque detected by the use of a perio- (A. G.) using a piezoelectric instrument dontal probe as modified by Tonetti with fine tips (EMS, Nyon, Switzerland) The sample size calculation determined et al. (2002). Similarly, a full-mouth and hand instruments, as appropriate. that 17 subjects per treatment arm would percentage bleeding score (FMBS) was Both groups received this treatment in provide 80% power to detect a true calculated after assessing dichoto- two long appointments during the same difference of 1.0 mm between test and mously the presence of bleeding on day. Two quadrants were instrumented placebo using probing pocket depth probing from the bottom of the pocket in a morning session, followed by the X (PPD) reduction in pockets 7mm as when probing with a manual probe with other two quadrants in an afternoon the primary outcome variable, assuming a force of 0.3 N (Tonetti et al. 2002). session. A 2 h session for each appoint- that the common standard deviation is Full-mouth PPD and recession of the ment was planned. Local anaesthesia 1.0 mm. Accordingly, a sample of 21 gingival margin (REC) were recorded at was used as necessary. Test subjects subjects per arm (42 in total) were to be the same time, with measurements received an adjunctive course of sys- recruited to compensate for possible rounded to the nearest millimetre. REC temic antibiotics consisting of 500 mg of drop-out during the study period. was recorded as a positive value if the amoxicillin and 500 mg of metronida- free gingival margin (FGM) occurred zole three times a day for 7 days, while Randomization and allocation apical to the cemeno–enamel junction control subjects received placebo. Sub- concealment (CEJ), whereas it was recoded as a jects were asked to take the first dose of negative value if it was coronal to the the medication before mechanical Subject numbers were assigned in CEJ. In the latter case, the examiner re- instrumentation had started at the first ascending order at the enrolment visit. inserted the probe angled 451 into the treatment session. All subjects used a Subjects were randomly assigned by a site in order to detect the CEJ. If the CEJ 0.2% chlorhexidine rinse (supplied to computer-generated table to receive one was not detectable for anatomical or re- improve complicance) twice a day for 2 of the two treatments. A balanced random storative reasons, the examiner adopted weeks post–treatment, and relied on permuted block approach (4-unit block clinical landmarks that were noted in the standard oral hygiene methods as size) was used to prepare the randomiza- case report forms. Lifetime cumulative instructed at the commencement of the tion tables in order to avoid unequal attachment loss (LCAL) was calculated study. balance between the two treatments. as PPD plus REC. Restricted randomization (minimization) took place, stratifying for smoking habits Post-treatment controls Investigator calibration (yes or no) and number of initial pockets The objectives of the post-treatment X5mm(o50, 50–80, 480). A total of 10 non-study subjects with appointments were to control and rein- The randomization table was sent to aggressive periodontitis were recruited force the oral hygiene habits of the the University College London (UCL) and used for the calibration exercise. subject, to monitor the early healing pharmacy, which prepared the medica- The single designated examiner (L. N.) events, report on any adverse events or tion for 50 subjects (25 tests and 25 measured full-mouth PPD and REC of additional medications taken. In addi- controls). Fifty plastic bags containing the gingival margin for all 10 subjects. tion, the 1-week post-treatment visit two bottles each (amoxicillin, metroni- On the same day (with a minimum served as a compliance control, as sub- dazole or placebo tablets) were sent back of 15 min separation), the examiner jects were asked to return any medica- to the study coordinator, who was the repeated the examination. Upon com- tion not taken and/or the empty bottles. only person who had access to them. pletion of all measurements, the intra- The number of pills not taken by the Consequently, the study coordinator examiner repeatability for LCAL subject was documented. completed the treatment assignment measurement was assessed. The exam- and matched the code of the plastic bag iner was judged to be reproducible after with the subject number. The research fulfilling the pre-determined success cri- Re-assessment examinations nurse provided the subject with the plas- teria (the percentage of agreement within Re-assessment visits occurred at 2 and 6 tic bag containing the two bottles. The Æ 2 mm between repeated measure- months after the completion of the treat- randomization code was not broken until ments had to be at least 98%). The ment. During these appointments, the all data had been collected and analysed. examiner showed 99.7% reproducibility. examiner recorded any medical history Thus, the treatment group was concealed changes, and the clinical periodontal to the patient, the clinical examiner, the Non-surgical periodontal therapy parameters recorded at the baseline visit therapist and the statistician. were repeated. At the end of the Periodontal therapy was initiated within appointment, a session of supragingival 1 month of the baseline screening exam- Clinical parameters debridement was performed as neces- ination. If for any reason, the initia- sary. No attempt was made to re-instru- Clinical parameters were assessed using tion of the therapy was delayed, a new ment residual periodontal pockets. a UNC-15 periodontal probe by the full-mouth periodontal examination was calibrated examiner at six sites/tooth performed. excluding third molars. Full-mouth pla- A standard cycle of periodontal ther- Primary and secondary outcome measures que score (FMPS) was recorded by apy consisting of oral hygiene instruc- assigning a binary score to each surface tions, supra- and sub-gingival mecha- The primary outcome measure of the (1 for plaque present, 0 for absent) and nical instrumentation of the root surface study was PPD reduction in sites with calculating the percentage of total tooth (scaling and root planing) was per- initial PPD X7 mm. Secondary out- surfaces that revealed the presence of formed by a single experienced therapist comes included differences between Treatment of generalized aggressive periodontitis 1099 groups for the (i) changes in mean full- Results 2004. Data entry of all information and mouth PPD and the changes in PPD and Subject accountability statistical analysis were performed by LCAL at different initial PPD cate- the end of September 2004. gories; (ii) changes in FMPS and Figure 1 shows what happened to all FMBS; (iii) percentage of sites with potential subjects throughout the study PPD reduction or LCAL gain of from possible recruitment to comple- Subject characteristics at baseline X tion. Fifty-one subjects were assessed 2 mm; (iv) percentage of sites that The baseline characteristics of the 41 showed LCAL loss X2 mm (disease for their eligibility before entering the study. Of these, 10 subjects were participants who were treated non-sur- progression); (v) percentage of sites gically with the adjunctive use of the with PPD changing from X5to excluded; seven because they did not meet the inclusion criteria, while the test or the placebo medication are dis- 44 mm and the percentage of sites with played in Table 1. The mean age of the PPD changing from X4to43mm other three refused to participate. One of the three who refused to participate participants was 31.3 Æ 5.2 years (SD) (need for re-treatment); (vi) description for the test group and 31.7 Æ 5.1 years and frequency of adverse events; did so after signing the consent form, but before treatment assignment had for the placebo group. Females and (vii) compliance with the systemic accounted for 80% of the test group medication. taken place. Thus, 41 subjects were randomly allocated to participate in the and 57% of the placebo group. In the study. All participants received the allo- test group 25% of the participants were Data management and statistical analysis cated intervention and one patient from smokers whereas 19% smoked in the the placebo group was lost to follow-up placebo group. Caucasians constituted Data were entered into an Excel (Micro- the major ethnic group in the study, soft office 2000) database and were between the 2-month visit and the 6-month visit because of reasons unre- accounting for 65% of the test group proofed for entry errors. The database and 47.6% of the placebo group. None was subsequently locked, imported into lated to the study. All participants were included in the analysis. of these demographic parameters SPSS for Windows (SPSS Inc. version showed a statistically significant differ- 11.0) formatted and analysed. A sub- ence between groups. ject-level analysis was performed by Study Schedule computing a subject-level variable Subject recruitment started in January (full-mouth or at different PPD cate- Clinical characteristics gories) for each of the parameters. 2003 and was completed by the end of Numerical data were summarized as December 2003. All the 6-month fol- The baseline examination revealed that means and 95% confidence intervals low-up visits were completed by July the two study groups showed similar (CIs), categorical data were summarized as frequency distribution and the per- 51 subjects assessed for centage-based measures (e.g. FMPS) eligibility were summarized as the median of the percentage and inter-quartile range. The 10 excluded: significance of differences between test Reasons: and placebo groups in terms of numer- Not meeting inclusion ical data was evaluated via univariate criteria (n=7) analysis using the independent samples Refused to participate (n=3) t-test. Likewise, the significance of the difference within each group before and after treatment was evaluated with the paired samples t-test. Categorical data 41 RANDOMIZED were analysed with the w2 test, and the percentage data between the two groups were compared with the Mann–Whitney 20 allocated to FSR with 21 allocated to FSR with test, while the within-group percentage amoxicillin and placebo medication changes were evaluated with the Wil- metronidazole coxon’s sign-rank test. The significance of the treatment option (test or placebo) 20 received allocated 21 received allocated on the dependent variables PPD reduc- intervention intervention tion and LCAL gain at different initial PPD categories was estimated by analy- sis of covariance (ANCOVA). The models Followed up at Followed up at were adjusted for baseline values and Week 1: n=20 Week 1: n=21 Week 5: n=20 Week 5: n=21 controlled for smoking. The final model Month 2. n=20 Month 2: n=21 was then selected by including signifi- Month 6: n=20 Month 6: n=20 cant factors only. Model estimates included adjusted means and 95% CIs. An intention-to-treat, last observation 20 ANALYSED 21 ANALYSED carried forward analysis was performed (Hollis & Campbell 1999). Fig. 1. Flow chart for study patients. 1100 Guerrero et al.

Table 1. Subject and clinical characteristics at baseline tically significant differences (po0.02) between test and placebo in the mean Parameter Test group Placebo group p-value (N 5 20) (N 5 21) PPD at moderate pockets (4–6 mm) and mean PPD at deep pockets (X7 mm). At Age 31.3 31.7 0.779 6 months, statistically significant differ- Mean (95% CI) (28.8, 33.7) (29.4, 34.1) t-test ences were detected between test and Females (percentage) 16 12 0.108 placebo groups in the mean PPD at 2 (80%) (57%) w moderate pockets (po0.02), mean Smokers (percentage) 5 4 0.719 PPD at deep pockets (p 0.001) and (25%) (19%) w2 o Caucasians (percentage) 13 10 0.530 LCAL at deep pockets (po0.05). (65%) (47.6%) w2 The significance of this treatment Teeth at baseline 25.5 26.0 0.482 effect between the groups at 2 and 6 Mean (95% CI) (24.5, 26.6) (25.0, 27.0) t-test months (difference between the test Number of pockets X5 mm 60.8 58.4 0.795 group and the placebo group in the Mean (95% CI) (46.3, 75.3) (46.74, 70.20) t-test mean PPD reduction and the mean Percentage of pockets X5 mm 35.5 31.5 0.514 LCAL gain at different pocket cate- Median (IQ) (26.6, 47.3) (24.4, 48.1) Mann–Whitney gories) is displayed in Table 3. Multi- Full-mouth plaque score 25.5 20.0 0.155 Median (IQ) (13.3, 36.8) (10.0, 29.0) Mann–Whitney variate models based on linear regression Full-mouth bleeding score 61.5 55.0 0.175 ANCOVA were constructed taking into Median (IQ) (50.8, 74.8) (35.5, 66.5) Mann–Whitney account the potential sources of variabil- ity such as smoking status and baseline pocket depth. As the adjustment for baseline PPD value could constitute a problem related to mathematical cou- pling (Tu et al. 2004), the same analyses were undertaken with a model that did not include an adjustment for baseline values. This resulted in almost identical results (data not shown). When consider- ing full-mouth mean LCAL, there were no statistically significant differences between test and placebo. Similarly when examining pockets 43mm, no differences were observed between test and placebo for either LCAL or PPD. For ease of presentation, these analyses have been omitted from Table 3. There were highly significant treat- ment effects for full-mouth PPD reduc- tion, PPD reduction at 4–6 mm pockets and PPD reduction at X7 mm pockets at 2 and 6 months, with the outcomes favouring the test treatment. For PPD Fig. 2. Baseline clinical (a) and radiographic (b) appearance of a 21-year-old, smoking reduction in 4–6 mm pockets, the female (eight cigarettes per day). She presented with a plaque score of 24%, a bleeding score adjusted differences between test and of 68% and 70 sites with pockets 5 mm or deeper. placebo treatment were 0.5 mm at 2 months and 0.4 mm at 6 months. In the deeper pockets X7 mm this differ- characteristics for number of teeth pre- (43 mm), moderate (4–6 mm) and ence was much larger: 0.9 mm at 2 sent, percentage of pockets X5 mm, deep (X7 mm) pocket categories for months and 1.4 mm at 6 months. plaque and bleeding levels, with no baseline, and the differences between For sites with initial PPD X7, LCAL significant differences between the baseline – 2 months and baseline – 6 gain was also significantly better in test groups. The data show that the subjects months are displayed in Table 2. At subjects: an adjunctive benefit of had retained most of their teeth, but had baseline, there were no significant dif- 0.6 mm at 2 months and 1.0 mm at 6 approximately a third of sites exhibit- ferences between test and placebo. All months was observed. While there was ing pockets requiring treatment and parameters, with the exception of the no statistically significant benefit in high levels of bleeding, but low levels mean LCAL gain at the initial shallow terms of 2-month LCAL gain of plaque (Fig. 2). pockets, showed a statistically signifi- (p 5 0.650) at sites with initial PPD cant difference between baseline and 4–6 mm, a highly significant difference 2 months. This was also true between of 0.50 mm in favour of the test group Mean values for clinical parameters baseline and 6 months except for LCAL was observed at 6 months (p 5 0.001). Mean full-mouth clinical outcomes and gain and PPD reduction at shallow In addition, the effect of smoking on mean clinical outcomes at shallow pockets. At 2 months, there were statis- the primary outcome variable (PPD Treatment of generalized aggressive periodontitis 1101

Table 2. Mean clinical outcome variables at baseline and differences between 0–2 and 0–6 months Clinical outcomes mean (95% CI) Group Baseline Difference between Difference between p-value paired t-test 0 months 0 and 2 months 0 and 6 months difference difference 0–2 months 0–6 months

Full-mouth mean PPD Placebo 4.1 0.8 0.7 o0.001 o0.001 (3.6, 4.5) (0.6, 1.1) (0.4, 1.0) Test 4.1 1.1 1.2 o0.001 o0.001 (3.6, 4.5) (0.9, 1.4) (0.9, 1.4) Mean PPD at pockets 43 mm Placebo 2.3 0.2 À 0.1 0.003 0.052 (2.2, 2.4) (0.1, 0.3) ( À 0.2, 0.0) Test 2.3 0.2 0.0 o0.001 0.931 (2.2, 2.3) (0.2, 0.3) (0.0, 0.0) Mean PPD at pockets 4–6 mm Placebo 5.0 1.2 1.0 o0.001 o0.001 (4.9, 5.1) (0.9, 1.5) (0.8, 1.3) Test 5.02 1.7 1.5 o0.001 o0.001 (4.9, 5.1) (1.6, 1.9) (1.3, 1.7) Mean PPD at pockets X7 mm Placebo 7.7 2.1 1.8 o0.001 o0.001 (7.4, 8.1) (1.6, 2.5) (1.3, 2.3) Test 7.7 3.0 3.1 o0.001 o0.001 (7.5, 7.9) (2.6, 3.3) (2.7, 3.5) Full-mouth mean LCAL Placebo 4.8 0.5 0.5 o0.001 o0.001 (4.1, 5.5) (0.3, 0.6) (0.2, 0.7) Test 4.7 0.7 0.8 o0.001 o0.001 (4.1, 5.2) (0.5, 0.8) (0.7, 0.9) Mean LCAL at sites with initial Placebo 3.2 0.0 0.0 0.683 0.704 pockets 43mm (2.7, 3.7) ( À 0.1, 0.1) ( À 0.2, 0.1) Test 2.9 0.0 0.0 0.631 0.634 (2.6, 3.1) ( À 0.01, 01) ( À 0.1, 0.1) Mean LCAL at sites with initial Placebo 5.7 0.8 0.8 o0.001 o0.001 pockets 4–6 mm (5.2, 6.2) (0.5, 1.0) (0.5, 1.1) Test 5.7 1.1 1.3 o0.001 o0.001 (5.3, 6.1) (1.0, 1.2) (1.2, 1.4) Mean LCAL at sites with initial Placebo 8.2 1.3 1.3 o0.001 o0.001 pockets X7mm (7.5, 8.9) (1.0, 1.6) (1.0, 1.6) Test 8.1 1.8 2.3 o0.001 o0.001 (7,7, 8.4) (1.6, 2.1) (2.0, 2.5)

PPD, probing pocket depth; LCAL, life cumulative attachment loss.

Table 3. Analysis of covariance for PPD reduction and LCAL gain at 2 and 6 months in different pockets categories

Multivariate ‘‘ANCOVA’’ analysis models Parameter Difference 0–2 months Difference 0–6 months

estimate p-value estimate p-value (95% CI) (95% CI)

Full-mouth mean PPD reduction Treatment group (test-placebo) 0.3 0.5 (0.1, 0.5) 0.002 (0.2, 0.7) 0.001 Smoking (no-yes) 0.4 0.4 (0.1, 0.7) 0.007 (0.1, 0.7) 0.040 Mean PPD reduction in pockets 4–6 mm Treatment group (test-placebo) 0.5 0.4 (0.2, 0.8) 0.001 (0.1, 0.7) 0.005 Smoking (no-yes) 0.4 0.2 (0.0, 0.8) 0.050 ( À 0.1, 0.6) 0.183 Mean PPD reduction in pockets X7 mm Treatment group (test-placebo) 0.9 1.4 (0.4, 1.5) 0.001 (0.8, 2.0) o0.001 Smoking (no-yes) 0.9 1.0 (0.3, 1.5) 0.007 (0.3, 1.7) 0.007 Mean LCAL gain in sites with initial PPD X7 mm Treatment group (test-placebo) 0.6 1.0 (0.2, 0.9) 0.002 (0.7, 1.3) o0.001 Smoking (no-yes) 0.6 0.7 (0.2, 1.0) 0.005 (0.3, 1.1) 0.001 Mean LCAL gain in sites with initial PPD 4–6 mm Treatment group (test-placebo) À 0.2 0.5 ( À 0.4, 0.0) 0.650 (0.2, 0.8) 0.001 Smoking (no-yes) 0.0 0.0 ( À 0.4, 0.2) 0.203 ( À 0.3, 0.4) 0.903 PPD, probing pocket depth; LCAL, life cumulative attachment loss. 1102 Guerrero et al. reduction at X7 mm pockets) was sta- between baseline and 6 months in both Percentage of sites with clinically relevant tistically significant (p 5 0.007), and the treatment groups. Furthermore, analysis changes difference between a non-smoker and a of the differences between test and A subset analysis was carried out to test smoker on PPD reduction at deep pock- placebo treatments for the outcome of the changes of some clinically relevant ets was 0.9 mm (95% CI 0.3, 1.5) at 2 treatment (baseline – 2 months) showed parameters at 2 and 6 months (Table 6). months and 1.0 mm (0.3, 1.7) at 6 a statistically significant difference All the median values (inter-quartile months. The corresponding value for (p 0.05) for the reduction in the per- o range) showed statistically significant the difference between non-smokers centage of pockets X5, X6 and X7mm differences favouring the test treatment and smokers on PPD reduction in initial that favoured the test treatment. The for the percentage of sites with LCAL pockets of 4–6 mm was 0.4 mm (0.0, statistical significance of the difference gain X2 mm at 2 months (p 5 0.047), at 0.8), demonstrating a borderline signifi- between baseline and 6 months was 6 months (p 5 0.028), the percentage of cance (p 5 0.050) at 2 months and a p 0.02 for the reduction in the percen- o sites with PPD reduction of X2mmat2 non-significant difference of 0.2 mm tage of pockets X5, X6 mm, and was months (p 5 0.029) and at 6 months ( 0.1, 0.6) at 6 months (p 5 0.183), p 0.05 for pockets X4, X7 mm. À o (p 5 0.021), and the percentage of pock- whereas there were no statistically sig- ets that had converted from X5mmat nificant differences for LCAL. baseline to 44 mm at 2 months (p 5 0.039) and at 6 months (p 5 0.008). Percentage of sites with pockets Oral hygiene and bleeding on probing Conversely, the percentage of sites with LCAL loss X2 mm was higher in The percentage of sites (median and FMPS and FMBS at baseline, and the the placebo group as compared with the inter-quartile range) with a PPD of a reduction (difference baseline – 2 test group at 2 months (p 5 0.041) and at specific threshold at baseline and the months and baseline – 6 months) within 6 months (p 5 0.072). reduction in the percentage of pockets each group are displayed in Table 5. The percentage of pockets that con- within groups (difference between base- Plaque scores decreased in both treat- verted from X4mm at baseline to line – 2 months and baseline – 6 ments from baseline to 2 months, and 43 mm at 2 months failed to show a months) are reported in Table 4. the difference was statistically signifi- statistically significant difference (p 5 The significance of the reduction in the cant for test and placebo groups. How- 0.112) while at 6 months the difference percentage of pockets between the ever, the 6-month plaque scores values between the groups demonstrated a sta- groups is also shown. At baseline, there were equal to baseline values. The tistical significance (p 5 0.038). were no statistically significant differ- effects of both treatments had a large ences between the groups in any of the impact on bleeding, and these changes specific PPD thresholds. were statistically significant at 2 and 6 Analysis within groups (Wilcoxon’s months (p 0.001). Furthermore, there Adverse events, concomitant o antimicrobials and compliance Signed rank test) indicated that all PPD was a statistically significant difference thresholds within each group showed a between test and placebo for the At the 1-week follow-up visit, 11 sub- highly statistically significant difference improvement in the percentage of bleed- jects (55%) in the test group and four between baseline and two months and ing sites at 2 and 6 months (po0.02). subjects (19%) in the placebo reported

Table 4. Percentage of pockets at baseline and differences between 0–2 and 0–6 months Median of percentage (IQ) Group Baseline Difference between Difference between p-value Wilcoxon’s signed- 0 and 2 months 0 and 6 months ranks test

difference difference 0–2 months 0–6 months

Percentage of pockets X4 mm Placebo 45.8 15.3 14.9 o0.001 o0.001 (33.7, 60.0) (9.4, 24.2) (7.6, 24.8) n Test 46.3 19.6 21.3 o0.001 o0.001 (37.6, 57.4) (16.1, 28.5) (14.6, 32.0) Percentage of pockets X5 mm Placebo 31.5 17.3 17.3 o0.001 o0.001 (24.9, 48.1) (10.9, 24.7) (9.2, 23.1) n nn Test 35.5 22.1 24.1 o0.001 o0.001 (26.6, 47.3) (19.5, 30.2) (19.2, 32.8) Percentage of pockets X6 mm Placebo 18.0 11.9 11.9 o0.001 o0.001 (13.0, 31.0) (7.0, 18.3) (4.1, 16.3) n nn Test 22.1 16.4 18.2 o0.001 o0.001 (13.2, 28.9) (11.5, 27.5) (10.7, 27.7) Percentage of pockets X7 mm Placebo 9.0 6.0 5.3 o0.001 0.001 (5.2, 17.3) (1.0, 11.5) (0.7, 10.5) n n Test 12.0 10.5 10.8 o0.001 o0.001 (5.8, 19.0) (5.7, 16.6) (5.6, 17.6) n Significant difference between groups favoring test treatment (po0.05). nn Significant difference between groups favoring test treatment (po0.02). Treatment of generalized aggressive periodontitis 1103

Table 5. Analysis on FMPS and FMBS at baseline (post-oral hygiene instructions) and differences between 0–2 and 0–6 months. Median (IQ) Group Baseline Difference Difference p-value Wilcoxon’ signed- 0–2 months 0–6 months ranks test

difference difference 0–2 months 0–6 months

Full-mouth plaque score (%) Placebo 20.0 3.0 0.0 0.029 0.112 (10.0, 29.0) ( À 1.0, 7.0) ( À 2.5, 8.0) Test 25.5 6.0 1.0 0.038 0.170 (13.3, 36.8) ( À 3.8, 19.0) ( À 5.0, 15.0) Full-mouth bleeding score (%) Placebo 55.0 17.0 21.0 o0.001 0.001 (35.5, 66.5) (10.0, 32.5) (9.5, 28.5) nn nn Test 61.5 34.5 32.0 o0.001 o0.001 (50.8, 74.8) (27.3, 34.5) (26.0, 39.0) nn Significant difference between groups favoring test treatment (po0.02). FMPS, full-mouth plaque score; FMBS, full-mouth bleeding score.

Table 6. Percentage of sites with clinically relevant changes in test and placebo groups at 2 and 6 months Median of percentage (IQ) 0–2 months data 0–6 months data

test group placebo p-value test group placebo p-value group Mann–Whitney test group Mann–Whitney test

Percentage of sites with X2mm 19.6 14.3 0.047 25.4 16.1 0.028 of LCAL gain at 2 months (15.5, 26.2) (8.6, 21.3) (18.5, 34.1) (8.8, 24.9) Percentage of sites with X2mm 29.4 20.8 0.029 30.2 20.8 0.021 of PPD reduction at 2 months (23.9, 43.8) (10.5, 32.7) (21.1, 46.6) (8.6, 32.7) Percentage of sites with LCAL 1.3 3.0 0.041 1.5 3.3 0.072 loss X2 mm at 2 months (0.3, 3.5) (1.8, 5.4) (1.2, 2.3) (1.5, 5.5) Percentage of pockets converting 71.2 56.6 0.039 74.1 54.2 0.008 from X5 mm at baseline to 44mm (63.3, 78.2) (30.4, 72.7) (63.7, 83.5) (29.1, 75.7) after treatment Percentage of pockets converting 49.0 41.6 0.112 55.2 37.2 0.038 from X4 mm at baseline to 43mm (42.9, 60.6) (21.1, 58.1) (38.9, 65.2) (18.0, 56.4) after treatment

LCAL, life cumulative attachment loss. adverse events. At the 5-week follow-up pills not taken by the non-compliant ment of GAP. The data indicated that visit only two subjects (10%) in the test patients were also documented. All sub- the experimental therapy resulted in group and one subject (4.8%) in the jects returned the medication bottles. clinically significant short-term im- placebo group reported to have continu- Sixteen subjects (80%) in the test group provements in clinical parameters. ing adverse events. The types of adverse and 19 subjects 90.5% in the placebo As all patients had pre-treatment ses- events at the 1- and 5-week follow-up group completed the course of systemic sions of oral hygiene instructions and visits are described in Table 7. Two medication as indicated. The reasons reinforcement as necessary, FMPS were subjects (one in the test group and one advocated by the four non-compliant low from the beginning of the study. in the placebo group) had a tooth extrac- subjects in the test group for not having There was little additional benefit to tion each between the baseline visit and taken all the pills were the following: plaque reduction from the therapy at 2 the 2-month visit. The baseline values of two subjects reported diarrhoea, one an 6 months, and there was no difference these two teeth were carried forward subject reported vomiting and one sub- between the treatment regimes. Pre-treat- through all the analysis. One subject ject failed to remember to take the ment sessions to achieve plaque scores from the test group lost three front teeth prescribed medication. These four sub- o20% were included in order to reduce because of an accident between the jects missed 38%, 45%, 52% and 9% of the impact of inadequate plaque control 2-month visit and the 6-month visit. the whole number of pills, respectively. in the success of non-surgical treatment The 2-month values of these three teeth (Magnusson et al. 1984). This was were carried forward to the 6-month visit. important because full-mouth instrumen- Concomitant antimicrobial medication tation was performed in two visits, and during the study period was recorded. Discussion thus the therapist had fewer opportunities Two subjects in the test group took This was the first randomized-controlled to deliver, check and reinforce the neces- amoxicillin capsules for medical reasons, clinical study (RCT) designed to assess sary oral hygiene instructions. while no subject in the placebo group the adjunctive effect of the metronida- Our experimental population con- had any concomitant antimicrobials. zole–amoxicillin antibiotic combina- sisted of subjects with the clinical char- Compliance with the course of sys- tion, originally proposed by van acteristics of GAP according to the temic medication and the number of Winkelhoff et al. (1989), in the treat- criteria of the 1999 international classi- 1104 Guerrero et al.

Table 7. Type of adverse events at the 1- and 5-week follow-up visit multivariate model (Table 3) determined that the additional benefit for test sub- Type of adverse event number Time period Test group, Placebo group, (percentage) of subjects (week) N 5 20 N 5 21 jects after taking into account the poten- tial sources of variability was 1.4 mm Stomach upset (nausea and vomiting) 1 3(15%) 0 (0.8, 2.0). It should be noted that the 5 1(5%) 0 results obtained in the control group Gastrointestinal disorder (diarrhea) 1 3(15%) 0 were within the range expected from 50 0non-surgical periodontal treatment in Headache 1 1(5%) 0 chronic periodontitis patients. Cobb 50 0 Periodontal abscess 1 0 2 (9.5%) (1996) reviewed the most relevant clin- 50 0ical studies related to PPD reduction Tooth loss, tooth extraction 1 0 0 after non-surgical therapy alone, and 5 1(5%) 1(4.8%) found that at deep pockets (PPDX Metallic taste 1 1(5%) 0 7 mm), the mean PPD reduction was 50 02.2 mm. This was in excellent agreement Intra-oral tissue alteration 1 0 2 (9.5%) with the results of our placebo group, 50 0which exhibited a mean PPD reduction General unwellness (irritability, flu, etc.) 1 3 (15%) 0 50 0of 2.1 mm at 2 months and 1.8 mm at 6 months. The results are also comparable with those of the control group in a fication (Armitage 1999). Because of analysis of previous studies in chronic similar study in aggressive periodontitis the recently reported difficulties encoun- periodontitis subjects and the lack of patients treated with the adjunctive use tered with this classification (Mombelli significant adjunctive benefit reported of three different single antibiotic regi- et al. 2002, Meyer et al. 2004), extra in studies that have used marginally mens (Sigusch et al. 2001). They showed efforts were directed towards selecting effective doses of antibiotic (Van Win- that in pockets 46 mm, a 2.3 mm PPD ‘‘clear cases’’. Our patients were mainly kelhoff et al. 1992, Winkel et al. 1997, reduction was achieved 6 months after Caucasians, with an average of 31 years Palmer et al. 1999). Attention has been treatment. The similarity between the of age, who presented with almost all drawn recently to the fact that the outcomes of subgingival instrumentation teeth and with severe widespread dis- amount of metronidazole needed for at deep pockets of chronic and aggres- ease (an average of 33% of the sites with effective concentration in body fluids sive periodontitis patients is in agree- PPD X5 mm after probing six sites amounts to 20–25 mg/kg, and that an ment with reports indicating that ag- around each tooth). Patients, however, insufficient antibiotic concentration gressive periodontitis patients respond were not screened or selected based would turn into a lack of effect on well to mechanical instrumentation upon a microbiological diagnosis. The clinical and microbiological parameters alone (Wennstrom et al. 1986). lack of microbiological entry criteria (Van Winkelhoff et al. 1999). This In contrast, the adjunctive benefits are had implications on the choice of anti- means that 1400–1750 mg/day of the more difficult to compare with other biotic regimen, and indicates that our medication should be taken by a 70 kg studies because of the paucity of rando- results are applicable to subjects where adult patient (Winkel et al. 1997). mized controlled clinical trial in GAP the antibiotic is used empirically, i.e. Therefore, in GAP patients with a high patients. Recent meta-analyses by Her- without specific targeting based on the prevalence of anaerobic and micro-aero- rera et al. (2002) and Haffajee et al. microbial results (Mombelli 2005, van philic periodontal pathogens, a moder- (2003) have suggested that the adjunc- Winkelhoff et al. 2005). Nevertheless, ate dose of amoxicillin (375–500 mg) tive benefit expected from antibiotic microbiological outcomes of treatment will have synergistic effects with usage may be greater in aggressive will be reported in a separate paper. metronidazole and its hydroxymetabo- periodontitis patients. An additional In this study, we prescribed 500 mg of lite against A. actinomycetemcomitans gain in LCAL of 0.7 mm was observed amoxicillin combined with 500 mg of (Pavicic et al. 1992), while a high dose in seven studies including 231 subjects metronidazole three times a day for of metronidazole (500 mg) will target receiving the antibiotic adjunctively to 7 days. This dosage has not been the anaerobic microflora. non-surgical or surgical root instrumen- reported in previous clinical trials. It It is clear from other clinical trials tation. In the present study, the use of aims to provide a wide spectrum of that mean full-mouth PPD and LCAL adjunctive antimicrobials resulted in an activity and to reach and maintain serum values may not be the best way to additional benefit of 0.5 mm in LCAL concentrations above the minimum describe the data. Shallow sites, which gain in moderate pockets (4–6 mm), effective concentration. The rationale are not expected to change as a result of while a 1.0 mm benefit was observed in for the wide spectrum has been pre- therapy, are likely to significantly dilute deeper pockets (X7 mm) compared with viously discussed and is based on the the changes observed at the deeper sites, non-surgical root debridement alone. reported high prevalence of A. actino- which are the ones of therapeutic con- Our test subjects showed a mean PPD mycetemcomitans and anaerobic patho- cern. Therefore, the primary outcome reduction of 3.1 mm in pockets X7mm gens in GAP patients (Sasaki et al. 1989, variable selected was the difference in at 6 months. These results are slightly Kamma et al. 1994, Listgarten et al. PPD reduction between the treatment inferior but comparable with the 6-month 1995, Lopez et al. 1995, Tonetti and groups at deep pockets. The mean PPD outcomes reported by Sigusch et al. Mombelli 1999, Ishikawa et al. 2002, reduction at 6 months was 1.8 mm (95% (2001) with the use of adjunctive metro- Lee et al. 2003, Takeuchi et al. 2003). CI 1.3, 2.3) for the placebo group and nidazole or clindamycin. In terms of PPD The choice of dosage comes from an 3.1 mm (2.7, 3.5) for the test group. A reduction at 6 months, the added benefit Treatment of generalized aggressive periodontitis 1105 that we observed was 0.4 mm for mod- patients, e.g. pocket reduction surgery. Dental Institute. L. N. is supported by a erate pockets (4–6 mm) and 1.4 mm for As reported in other studies (Loesche fellowship from the Italian Society of the deep pockets (X7mm).Thisgradient et al. 1992, Smith et al. 2002), we Periodontology, SIdP. of effect is consistent with the notion that compared the reduction in the frequency the benefit of the antibiotic is particularly of sites in test and control patients evident at deeper pockets where mechan- who would require surgical intervention ical debridement is less effective. for PPD reduction at 2 or 6 months using References The multivariate analysis identified 5 mm as the discriminant value. At 2 Apatzidou, D. A. & Kinane, D. F. (2004) Quad- cigarette smoking as a significant factor months post-therapy, we found that rant root planing versus same-day full-mouth (p 5 0.007): in a non–smoker, deep the subjects receiving the test treat- root planing. I. Clinical findings. Journal of pockets reduced by an average of ment showed a 71% reduction in the Clinical Periodontology 31, 132–140. 0.9 mm more than in a smoker, regard- number of sites in need of surgical inter- Armitage, G. C. (1999) Development of a less of the treatment group. This result is vention, while the subjects in the placebo classification system for periodontal diseases in accordance with previous studies that group had a reduction of 57% and conditions. Annals of Periodontology 4, have demonstrated, in chronic perio- (p 5 0.039). These values were main- 1–6. Berglundh, T., Krok, L., Liljenberg, B., West- dontitis patients, that less PPD reduction tained at 6 months. Using an even stricter felt, E., Serino, G. & Lindhe, J. (1998) The and less LCAL gain occur in smokers as discriminant value (4 mm), at 6 months, use of metronidazole and amoxicillin in the compared with non-smokers (Preber and 55% of the test sites with baseline pock- treatment of advanced periodontal disease. A Bergstrom 1986, Jin et al. 2000) or even ets showed maintainable probing depths prospective, controlled clinical trial. Journal former smokers (Grossi et al. 1997). (3 mm or less) as compared with 37% of of Clinical Periodontology 25, 354–362. For most clinicians, results reported the placebo sites (p 5 0.038). Bollen, C. M., Vandekerckhove, B. N., as mean full-mouth values offer little Two subjects in the placebo group Papaioannou, W., van Eldere, J. & Quirynen, insight into the clinical relevance of the and four subjects in the test group did M. (1996) Full- versus partial-mouth disinfec- findings. To illustrate tangible clinical not fully comply with the medication. tion in the treatment of periodontal infections. A pilot study: long-term microbiological benefits, after the analysis on the pri- The fact that 20% of test subjects did not observations. Journal of Clinical Perio- mary outcome variable (PPD reduction complete the full cycle of antibiotic may dontology 23, 960–970. in pockets X7 mm) and the other para- have led to an underestimation of the Buchmann, R., Nunn, M. E., Van Dyke, T. E. & meters based on full-mouth mean or adjunctive effect in our intention-to- Lange, D. E. (2002) Aggressive periodontitis: median values, secondary analyses treat analysis. On the other hand, this 5-year follow-up of treatment. Journal of were carried out. Accordingly, the test fact provides the study with a higher Periodontology 73, 675–683. treatment significantly decreased the external validity as lack of compliance Cobb, C. M. (1996) Non-surgical pocket ther- percentage of pockets that remained is a reality in clinical practice (Grob apy: mechanical. Annals of Periodontology 1, 443–490. above specific thresholds at 2 and 6 1992). Furthermore, given the fact that Flemmig, T. F., Milian, E., Karch, H. & Klai- months after subgingival debridement some of the observed incomplete com- ber, B. (1998) Differential clinical treatment (Table 6). As in previous studies (Ber- pliance can be attributed to the onset of outcome after systemic metronidazole and glundh et al. 1998), the percentage of all significant side effects, clinicians pre- amoxicillin in patients harboring Actinoba- sites that gained X2 mm in LCAL and scribing this regimen to their patients cillus actinomycetemcomitans and/or Por- the percentage of all sites that had a PPD should expect less than optimal compli- phyromonas gingivalis. Journal of Clinical reduction X2 mm were statistically sig- ance. An additional analysis assessing Periodontology 25, 380–387. nificantly higher in the test group at the impact of incomplete compliance Greenstein, G. (2002) Full-mouth therapy ver- 2 and 6 months. Furthermore, the per- will be presented in a companion sus individual quadrant root planning: a cri- tical commentary. Journal of Periodontology centage of sites experiencing disease paper focused on the microbiological 73, 797–812. progression (LCAL loss of 2 mm or outcomes of the study where an ‘‘on- Grob, P. R. (1992) Antibiotic prescribing prac- more over the 6-month observation per- drug’’ analysis gives important addi- tices and patient compliance in the commu- iod) was significantly decreased by the tional information. nity. Scandinavian Journal of Infectious antibiotic combination. In conclusion, the findings of the Diseases 83 (Suppl.), 7–14. However, a critical question at re- present study have indicated that the Grossi, S. G., Zambon, J., Machtei, E. E., evaluation 3–6 months after the comple- adjunctive use of systemic amoxicillin Schifferle, R., Andreana, S., Genco, R. J., tion of non-surgical therapy is related to plus metronidazole, during full-mouth Cummins, D. & Harrap, G. (1997) Effects of what to do with residual pockets and the non-surgical cause-related periodontal smoking and smoking cessation on healing after mechanical periodontal therapy. Journal need for further treatment beyond main- treatment (FSR) performed within 24 h, of the American Dental Association 128, tenance care. A recent systematic has resulted in significant additional 599–607. review on the clinical parameters used improvements in the clinical conditions Haffajee, A. D., Socransky, S. S. & Gunsolley, during re-evaluation (residual pockets, of GAP patients when compared with J. C. (2003) Systemic anti-infective perio- bleeding on probing and presence of FSR alone. These observations are valid dontal therapy. A systematic review. Annals furcation defects) to predict further for both the 2- and 6-month evaluations of Periodontology 8, 115–181. attachment loss (Renvert & Persson after the completion of active treatment. Herrera, D., Sanz, M., Jepsen, S., Needleman, I. 2002) concluded that the presence of & Roldan, S. (2002) A systematic review on the effect of systemic antimicrobials as an deep residual pockets was associated adjunct to scaling and root planing in perio- with further disease progression and Acknowledgements dontitis patients. Journal of Clinical Perio- hence decreased maintainability. This dontology 29 (Suppl. 3), 136–159. conclusion can be used as a rationale This study was supported by the Perio- Hollis, S. & Campbell, F. (1999) What is meant for providing further treatment to dontal Research Fund of the Eastman by intention to treat analysis? Survey of 1106 Guerrero et al.

published randomised controlled trials. Brit- Mongardini, C., van Steenberghe, D., Dekeyser, cal procedure and systemic antibiotics in the ish Medical Journal 319, 670–674. C. & Quirynen, M. (1999) One stage full- treatment of rapidly progressive periodontitis. Ishikawa, I., Kawashima, Y., Oda, S., Iwata, T. versus partial-mouth disinfection in the Journal of Periodontology 72, 275–283. & Arakawa, S. (2002) Three case reports treatment of chronic adult or generalized Smith, S. R., Foyle, D. M., Daniels, J., Joyston- of aggressive periodontitis associated with early-onset periodontitis. I. Long-term clin- Bechal, S., Smales, F. C., Sefton, A. & Porphyromonas gingivalis in younger ical observations. Journal of Periodontology Williams, J. (2002) A double-blind placebo- patients. Journal of Periodontal Research 37, 70, 632–645. controlled trial of azithromycin as an adjunct 324–332. Palmer, R. M., Matthews, J. P. & Wilson, R. F. to non-surgical treatment of periodontitis in Jin, L., Wong, K. Y., Leung, W. K. & Corbet, E. (1999) Non-surgical periodontal treatment adults: clinical results. Journal of Clinical F. (2000) Comparison of treatment response with and without adjunctive metronidazole Periodontology 29, 54–61. patterns following scaling and root planing in in smokers and non-smokers. Journal of Takeuchi, Y., Umeda, M., Ishizuka, M., Huang, smokers and non-smokers with untreated Clinical Periodontology 26, 158–163. Y. & Ishikawa, I. (2003) Prevalence of adult periodontitis. Journal of Dentistry 11, Pavicic, M. J., Van Winkelhoff, A. J. & de periodontopathic bacteria in aggressive perio- 35–41. Graaff, J. (1991) Synergistic effects between dontitis patients in a Japanese population. Kamma, J. J., Nakou, M. & Manti, F. A. (1994) amoxicillin, metronidazole, and the hydroxy- Journal of Periodontology 74, 1460–1469. Microbiota of rapidly progressive perio- metabolite of metronidazole against Actinoba- Tonetti, M. S., Lang, N. P., Cortellini, P., Suvan, dontitis lesions in association with clinical cillus actinomycetemcomitans. Antimicrobial J. E., Adriaens, P., Dubravec, D., Fonzar, A., parameters. Journal of Periodontology 65, Agents and Chemotherapy 35, 961–966. Fourmousis, I., Mayfield, L., Rossi, R., Sil- 1073–1078. Pavicic, M. J., Van Winkelhoff, A. J. & de vestri, M., Tiedemann, C., Topoll, H., Kinane, D. F. (2005) Single-visit, full-mouth Graaff, J. (1992) In vitro susceptibilities of Vangsted, T. & Wallkamm, B. (2002) Enamel ultrasonic debridement: a paradigm shift in Actinobacillus actinomycetemcomitans to a matrix proteins in the regenerative therapy of periodontal therapy? Journal of Clinical number of antimicrobial combinations. Anti- deep intrabony defects. Journal of Clinical Periodontology 32, 732–733. microbial Agents and Chemotherapy 36, Periodontology 29, 317–325. Koshy, G., Kawashima, Y., Kiji, M., Nitta, H., 2634–2638. Tonetti, M. S. & Mombelli, A. (1999) Early- Umeda, M., Nagasawa, T. & Ishikawa, I. Pavicic, M. J., Van Winkelhoff, A. J., Douque, onset periodontitis. Annals of Periodontology (2005) Effects of single-visit full-mouth N. H., Steures, R. W. & de Graaff, J. (1994a) 4, 39–53. ultrasonic debridement versus quadrant-wise Microbiological and clinical effects of metro- Tu, Y. K., Maddick, I. H., Griffiths, G. S. & ultrasonic debridement. Journal of Clinical nidazole and amoxicillin in Actinobacillus Gilthorpe, M. S. (2004) Mathematical cou- actinomycetemcomitans Periodontology 32, 734–743. -associated perio- pling can undermine the statistical assess- Journal of Lee, J. W., Choi, B. K., Yoo, Y. J., Choi, S. H., dontitis. A 2-year evaluation. ment of clinical research: illustration from Clinical Periodontology 21, 107–112. the treatment of guided tissue regeneration. Cho, K. S., Chai, J. K. & Kim, C. K. (2003) Pavicic, M. J., Van Winkelhoff, A. J., Pavicic- Journal of Dentistry 32, 133–142. Distribution of periodontal pathogens in Kor- Temming, Y. A. & de Graaff, J. (1994b) Vandekerckhove, B. N., Bollen, C. M., Dekey- ean aggressive periodontitis. Journal of Amoxycillin causes an enhanced uptake of ser, C., Darius, P. & Quirynen, M. (1996) Periodontology 74, 1329–1335. metronidazole in Actinobacillus actinomyce- Full- versus partial-mouth disinfection in the Listgarten, M. A., Wong, M. Y. & Lai, C. H. temcomitans: a mechanism of synergy. Jour- treatment of periodontal infections. Long- (1995) Detection of Actinobacillus actinomy- nal of Antimicrobial Chemotherapy 34, term clinical observations of a pilot study. cetemcomitans, Porphyromonas gingivalis, 1047–1050. Journal of Periodontology 67, 1251–1259. and Bacteroides forsythus in an A. actinomy- Preber, H. & Bergstrom, J. (1986) The effect of Wennstrom, A., Wennstrom, J. & Lindhe, J. cetemcomitans-positive patient population. non-surgical treatment on periodontal pock- (1986) Healing following surgical and non- Journal of Periodontology 66 , 158–164. ets in smokers and non-smokers. Journal of surgical treatment of juvenile periodontitis. A Loesche, W. J., Giordano, J. R., Hujoel, P., Clinical Periodontology 13, 319–323. 5-year longitudinal study. Journal of Clinical Schwarcz, J. & Smith, B. A. (1992) Metro- Quirynen, M., Bollen, C. M., Vandekerckhove, Periodontology 13, 869–882. nidazole in periodontitis: reduced need for B. N., Dekeyser, C., Papaioannou, W. & Wennstrom, J. L., Tomasi, C., Bertelle, A. & surgery. Journal of Clinical Periodontology Eyssen, H. (1995) Full- vs. partial-mouth Dellasega, E. (2005) Full-mouth ultrasonic 19, 103–112. disinfection in the treatment of periodontal debridement versus quadrant scaling and root Lopez, N. J., Mellado, J. C., Giglio, M. S. & infections: short-term clinical and microbio- planing as an initial approach in the treatment Leighton, G. X. (1995) Occurrence of certain logical observations. Journal Dental Re- of chronic periodontitis. Journal of Clinical bacterial species and morphotypes in juvenile search 74, 1459–1467. Periodontology 32, 851–859. periodontitis in Chile. Journal of Perio- Renvert, S. & Persson, G. R. (2002) A systema- Winkel, E. G., Van Winkelhoff, A. J., Timmer- dontology 66, 559–567. tic review on the use of residual probing man, M. F., van der Velden, U. & Van der Magnusson, I., Lindhe, J., Yoneyama, T. & depth, bleeding on probing and furcation Weijden, G. A. (2001) Amoxicillin plus Liljenberg, B. (1984) Recolonization of a status following initial periodontal therapy metronidazole in the treatment of adult perio- subgingival microbiota following scaling in to predict further attachment and tooth loss. dontitis patients. A double-blind placebo-con- deep pockets. Journal of Clinical Perio- Journal of Clinical Periodontology 29 trolled study. Journal of Clinical dontology 11, 193–207. (Suppl. 3), 82–89. Periodontology 28, 296–305. Meyer, J., Lallam-Laroye, C. & Dridi, M. Rooney, J., Wade, W. G., Sprague, S. V., Winkel, E. G., Van Winkelhoff, A. J., Timmer- (2004) Aggressive periodontitis – what Newcombe, R. G. & Addy, M. (2002) man, M. F., Vangsted, T. & van der Velden, exactly is it? Journal of Clinical Perio- Adjunctive effects to non-surgical perio- U. (1997) Effects of metronidazole in patients dontology 31, 586–587. dontal therapy of systemic metronidazole with ‘‘refractory’’ periodontitis associated Mombelli, A. (2005) Antimicrobial profiles of and amoxycillin alone and combined. A with Bacteroides forsythus. Journal of Clin- periodontal pathogens and systemic antimi- placebo controlled study. Journal of Clinical ical Periodontology 24, 573–579. crobial therapy. Journal of Clinical Perio- Periodontology 29, 342–350. Winkel, E. G., Van Winkelhoff, A. J. & van der dontology 32, 891–892. Sasaki, N., Nakagawa, T., Seida, K., Ishihara, Velden, U. (1998) Additional clinical and Mombelli, A., Casagni, F. & Madianos, P. N. K. & Okuda, K. (1989) Clinical, microbiolo- microbiological effects of amoxicillin and (2002) Can presence or absence of perio- gical and immunological studies of post- metronidazole after initial periodontal ther- dontal pathogens distinguish between subjects juvenile periodontitis. Bulletin of Tokyo apy. Journal of Clinical Periodontology 25, with chronic and aggressive periodontitis? A Dental College 30, 205–211. 857–864. systematic review. Journal of Clinical Perio- Sigusch, B., Beier, M., Klinger, G., Pfister, W. van Winkelhoff, A. J., Herrera, D., Oteo, A. & dontology 29 (Suppl. 3), 10–21. & Glockmann, E. (2001) A 2-step non-surgi- Sanz, M. (2005) Antimicrobial profiles of Treatment of generalized aggressive periodontitis 1107

periodontal pathogens isolated from perio- van Winkelhoff, A. J., Tijhof, C. J. & de Graaff, Address: dontitis patients in the Netherlands and Spain. J. (1992) Microbiological and clinical results Maurizio S. Tonetti Journal of Clinical Periodontology 32, of metronidazole plus amoxicillin therapy in Department of Periodontology 893–898. Actinobacillus actinomycetemcomitans-asso- University of Connecticut Health Center van Winkelhoff, A. J., Rodenburg, J. P., Goene, ciated periodontitis. Journal of Perio- 263 Farmington Ave R. J., Abbas, F., Winkel, E. G. & de Graaff, J. dontology 63, 52–57. Farmington, CT 06030 (1989) Metronidazole plus amoxycillin in the van Winkelhoff, A. J., Winkel, E. G. & Van- USA treatment of Actinobacillus actinomycetem- denbroucke-Grauls, C. M. (1999) On the E-mail: [email protected] comitans associated periodontitis. Journal of dosage of antibiotics in clinical trials. Journal Clinical Periodontology 16, 128–131. of Clinical Periodontology 26, 764–766.

Clinical relevance Principal findings: Subjects strated by the reduced prevalence of Scientific rationale for study: receiving the adjunctive amoxicillin pockets. Adjunctive systemic antibiotics may and metronidazole combination Practical implications: Patients benefit aggressive periodontitis demonstrated statistically significant with generalized aggressive perio- patients during non-surgical therapy. additional improvements in clinical dontitis may benefit from the adjunc- Insufficient data, however, exist sup- outcomes with respect to debride- tive administration of amoxicillin porting this approach. ment alone. The improvements and metronidazole during the initial were clinically significant, as demon- phase of periodontal treatment.