Comparison of Systemic Ciprofloxacin in Elimination of A.a from Active Sites with Combination of Metronidzole and Amoxicillin in Patients with Aggressive Periodontitis: A Randomized Double Blind Controlled Trial Y. Soleymani Shayesteh 1, A. Khorsand 1, MH. Salary 2, H. Mehrizy 3 1 Assistant Professor, Department of Periodontology, Faculty of Dentistry, Tehran University of Medical Science, Tehran, Iran 2 Associate Professor, Department of Microbiology, Faculty of Public Health, Tehran University of Medical Science 3 Assistant Professor, Department of Periodontology, Faculty of Dentistry, Rafsanjan University of Medical Science, Tehran, Iran Statement of Problem: The elimination of Actinobacillus actinomycetemcomitans (A.a) is a key factor for achieving a successful treatment in patients with aggressive periodontitis (AgP) whom harboring this organism. This micro organism s capability to invade to host s tissues, makes its eradication with mechanical therapy (eg. flap surgery, scaling, oral hygiene) very difficult, so there is no other way than using a systemic antibiotic. But which antibiotic is the best one? The Ciprofloxacin is the only antibiotic which can suppress all strains of A.a. Purpose: The aim of this study was to compare the effectiveness of Ciprofloxacin in elimination of A.a in active sites of AgP patients with combination of Metronidazole and Amoxicillin. Materials and Methods: This study was a randomized double blind controlled clinical trial. Twenty four patients with clinical diagnosis of AgP and detection of A.a in their pockets were randomly divided into two groups. The 12 patients in test group received Ciprofloxacin (10 days BID 1gr) plus the placebo capsules representing Metronidazole and Amoxicillin. The other 12 patients named control group, received Metronidazole (7 days TID 750mg) plus Amoxicillin (7 days TID 1.5gr) and the placebo tablet representing Ciprofloxacin. Neither the patients nor the doctors knows the grouping sequences. Bacteria Culturing and measurement of Gingival Index (GI) and plaque Index (PI) were done at the baseline and repeated about 10 days after prescribing the medicines. T- test and chi-square test were used for Statistical analysis. Results: There was no difference between two groups in the A.a Positives sites, GI scores and PI scores at the baseline. Ciprofloxacin eliminates A.a from 91.7% of sites and Metronidazole plus Amoxicillin eliminate A.a from 81.3% of sites. There was no significant difference between the test and control groups. The mean PI score for test and control groups were 1.39±0.66 and 1.39±0.88 respectively at the baseline and these values were 1.27±0.6 and 1.43±0.81 after receiving the designed medicine. There were no differences inter and intra groups at any time (P>0.05). Conclusion: Ciprofloxacin is as effective as Metronidazole plus Amoxicillin in elimination of A.a from active sites in AgP patients. Their longitudinal effects on clinical parameters such as probing depth, clinical attachment level, bleeding on probing and microbial flora need to be investigated. Key words: Systemic antibiotic; Ciprofloxacin; Aggressive periodontitis; Actinobacillus actinomycetemcomitans, Tehran, Iran () 24
T he relationship between Actinobacillus actinomycetemcomitans (A.a) and the localized aggressive periodontitis has been confirmed by many investigators. (1-5) A.a has many virulent potentials such as leukotoxins, (6) tissue invasion factors, (7,8) and different enzymes, (6) which enable it to colonize and proliferate in the subgingival area and cause periodontal destruction, specially in susceptible patients. So the elimination of A.a is a key factor for achieving a successful clinical outcome in patients with the A.a associated periodontitis. (1,2,9-18) Tissue invasion is an important virulent factor and help the bacteria to escape from mechanical debridement. (7,8) Many studies have shown that, mechanical therapy alone, cannot eliminate A.a (9-14, 16-26) from subgingival areas. So different antibiotic regimen have been proposed to eliminate A.a from active sites in patients whom harboring this bacteria. Tetracycline as a monotherapy and combination of Metronidazole and Amoxicillin have been used in suppression of A.a and successful results have been reported. (11 17, 24-32) However there are studies which showed, tetracycline cannot eliminate A.a in some cases. (21,33) Flouroquinolones were introduced in early 1990 for suppressing of non-oral rods in periodontal pockets, (34-36) but susceptibility tests showed that this antibiotic is useful for facultative bacteria and ciprofloxacin is the only antibiotic which can suppress all strains of A.a in periodontal therapy. (37) Since in-vitro studies are not enough for stablishing the routine use of a drug, clinical usefulness of an antibiotic need to be investigated by in-vivo clinical trials. (38) The aim of present study was to compare the effectiveness of systemic Ciprofloxacin in eradication of A.a from subgingival areas with the combination of Metronidazole plus Amoxicillin as a gold standard. (35,39) patients with clinical diagnosis of aggressive periodontitis (AgP) were enrolled in to the study. They were divided randomly in to the test and control group. All the patients had at least 18 years old and have not received any antibiotic and periodontal treatment for the last 6 month. Another inclusion criteria was absence of any systemic disease. Each patient had at least 4 A.a positive sites which were bleeding easily on probing and had more than 5 mm probing pocket depth. In the test group the patients received Ciprofloxacin plus the placebo pills (capsules) representing Metronidazole and Amoxicillin and in the control group the patients received Metronidazole plus Amoxicillin and the placebo pills of Ciprofloxacin (blinding). Sampling from the same sites were repeated at the baseline and 10 days after start of the therapy. Gingival Index (GI) (Loe and Silness) and plaque index (PI) (Silness and Loe ) were also recorded at the same intervals. No mechanical therapy such as scalling and root planning or oral hygiene instruction were performed. After second sampling the patients were treated with the appropriate approach. Samples were obtained from deepest pocket of each quadrant using 2 No 30 paper points (Aria dent, Iran). The paper points were inserted in the selected sites until the resistance of the tissue did not allow further penetration. The paper points remained in the pockets for 20-30 seconds. Then they were transferred to the laboratory by BHI solution. Samples were cultured on TSBV as described by Mandell and Socransky. (5) All plates were monitored for starlike colonies of A.a after two days of incubation, by using a light microscope. A sample diagnosed free from A.a if there was no A.a colony in the related plate. The results were compared using independent sample t test and Chi-Square test between two groups. Materials and Methods In a randomized double blind clinical trial, 24 Results There were no differences between two groups 25
in age and/or sex. Test group included of 10 women and 2 men with the mean age of 25.6 ± 6.7 and control group consisted of 9 women and 3 men with then mean age of 26.9 ± 5.8 (P>0.05). Also there was no difference in GI and PI scores between two groups at the base line. Ciprofloxacin eliminated A.a from 91.7% of positive sites and Metronidazole plus Amoxicillin eliminated A.a from 81.3% of positive sites (P>0.05). There was no significant difference between the test and control group using t-test and Pearson chi-square test after receiving the designed medicine. The mean PI score for test and control were 1:39±0.66 and 1.43±0.81 respectively there was no differences inter and intra group at any time. GI score for test and control groups were 1.53±0.61 and 1.58±0.82 respectively at the baseline and 1.19±0.5 and 1.32±0.72 after therapy. There was no difference inter and intra group at any time. (P>0.05) Discussion The results of this study showed that Ciprofloxacin was as effective as Metronidazole plus amoxicillin in elimination of A.a from active sites in patients with aggressive periodontitis. The importance of eradication of A.a in achieving successful results in the treatment of A.a associated periodontitis explained by many studies. (1,2,9-18) Although, the prevention of recolonization of A.a cannot be achieved without professional scalling and root planning and practicing good oral hygiene, these are not the issues of the present study. This study tried to find an appropriate antibiotic for elimination of the A.a and not the best approach for maintaining the successful results. Most of the studies about the antibiotics in dental literature are about the additive and adjunctive effects of this medicines after conventional mechanical therapy (10,11,13,16,17, 19,26,28,29,31,32) because there is a general agreement on biofilm effect of dental plaque in protection of the bacteria. (38) Direct comparison between two antibiotic and evaluation of the effects of these drugs as a monotherapy is seldom in dental literature. Usually mechanical therapies are performed and these procedures act as a confounder. So net conclusion is impossible, and selection of appropriate antibiotic is a matter of prefferance instead of documented investigations. Most of informations about antibiotics come from in-vitro studies and susceptibility tests. Some review articles offered the combination of metronidazole plus amoxicillin as the first choice in the treatment of A.a associated periodontitis, and when the patient has allergy to penicillins, Ciprofloxacin can be used as a second choice. (38,39) If Ciprofloxcin is as effective as that combination, it could be used as the first choice, because it is simpler to use for patients (one drug versus two) and has lesser side effects (40).The elimination of A.a by these two regimen as a monotherapy showed that at least some part of the effects of the antibiotics influenced by dental plaque biofilm. In other word, the elimination of A.a cannot be resisted by protection effect of dental plaque. Some periodontopathic bacteria (eg. A.a) are unattached bacteria which live in subgingival area in the soft tissue wall of the pocket, even in the healthy periodontium. This part of periodontium is not protected by structures of dental plaque and can be eliminated by systemic antibiotics. It doesn t mean that there is no need for mechanical therapy, however explains the effects of systemic antibiotic therapy in some periodontitis. No changing in gingival Index can be explained with the same approach. In fact this index and other current indices showed the inflammatory conditions in the marginal gingival. These conditions are dictated by marginal plaque, which is mostly forms attached plaque. Mature structure of the biofilm in this region protect the 26
bacterium against systemic antibiotic. Therefore, microbial changes in the depth of the pocket does not have visible and clinical reflection at marginal gingiva. The mechanical debridement is a powerful and effective tool for elimination of marginal gingivitis and maintaining the periodontium from recolonization by periodontopathic bacteria, but cannot eliminate periodontophatic bacteria from the depth of the pocket and periodontal tissues. There are controversies about the selection of suitable antibiotic in periodontology field. Conducting such studies help to find an appropriate antibiotic regimen for each bacteria by direct comparison between two or more antibiotic without any confinder. References: Conclusion Ciprofloxacin is as effective as Metronidazole plus amoxicillin in elimination of A.a from active sites in patients with aggressive periodontitis. Since it has lesser side effects, Ciprofloxacin can be used as the first choice in the treatment of A.a associated periodontitis. Additive effects of Ciprofloxacin after SRP and its longitudinal effects on clinical parameters need to be investigated. Using similar studies and by which such a study comparing two or more different antibiotic regimen, informations about their effectiveness on eradication of some important periodontopathic bacteria can be found. 1- Mandell RL, Ebersole JL. Clinical immunologic and microbiologic features of active disease sites in JP. J Clin Periodontol 1987; 14: 534-40. 2- Haffajee AD, Socransky SS. Clinical, microbiologic and immunological features associated with the treatment of active periodontal lesions. J Clin Periodontol 1984;11: 600-18. 3- Zambon JJ, Christersson LA. A.a in human periodontal disease; prevalence in patient groups and distribution of biotypes and serotypes within families. J Periodontol 1983; 54: 707-11. 4- Socransky SS, Haffajee AD. The bacterial etiology of destructive periodontal disease; current concepts. J Periodontol 1992; 63: 222. 5- Mandell RL, Socransky SS. A selective medium for A.a and the incidence of organism in JP. J Periodontol 1981; 52: 593-98. 6- Newman MG, Takei HH, Carranza FA. Clinical Periodontolgy. 9 th ed. Philadelphia: WB Saunders; 2002. 7- Blix J. Entrance of A.a into HEP-2 cells in-vitro. J Periodontol 1992; 63: 723-28. 8- Streenivasan M, Meyer PH. Requirement for invasion of epithelial cells by A.a. Infection Immunity 1993; 61: 1239-45. 9- Solts JR. Suppression of the peridontopathic microflora in LJP by systemic tetracycline. J Clin Periodontol 1983; 10: 465-86. 10- Kornman KS, Robertson PB. Clinical and microbiological evaluation of therapy for juvenile Periodontitis. J Periodontol 1985; 56: 443-46. 11- Mandell RL, Socransky SS. Microbiological and clinical surgery plus doxycycline on juvenile peridontitis. J Periodontol 1988; 59: 373-79. 12- Van Winkelhoff AJ, Carolien J. Microbiological and clinical results of Metronidazol plus Amoxicillin therapy in A.a associated periodontitis. J Periodontol 1992; 63: 52-57. 13- Mandell RL, Tripodil LS, Savitt E, Goodson JM, Savansky SS. The effect of treatment on A.a in LJP. J Periodontol 1988; 57: 94-99. 14- Perus HR. Treatment of rapidly-destructive periodontitis in Papillon-Lefever syndrome; laboratory and clinical observation. J Clin Peridontol 1988; 15: 639-43. 15- Aass AM, Preus HR. Association between detection of oral A.a and radiographic bone loss in teenagers; a 4-year longitudinal study. J Periodontol 1992; 63: 682-85. 27
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