Skip to main content

An estimate of pocket closure and avoided needs of surgery after scaling and root planing with systemic antibiotics: a systematic review

Abstract

Background

Relevant benefits of adjunctive medication of antibiotica after conventional root surface debridement in terms of enhanced pocket depth (PD) reduction have been shown. However, means and standard deviations of enhanced reductions are difficult to translate into clinical relevant treatment outcomes such as pocket resolution or avoidance of additional surgical interventions. Accordingly, the aim of this systematic review was to calculate odds ratios for relevant cut-off values of PD after mechanical periodontal treatment with and without antibiotics, specifically the combination of amoxicilline and metronidazol, from published studies. As clinical relevant cut-off values “pocket closure” for PD ≤ 3mm and “avoidance of surgical intervention” for PD ≤ 5 mm were determined.

Methods

The databases PubMed, Embase and Central were searched for randomized clinical studies assessing the beneficial effect of the combination of amoxicillin and metronidazole after non-surgical mechanical debridement. Titles, abstracts and finally full texts were scrutinized for possible inclusion by two independent investigators. Quality and heterogeneity of the studies were assessed and the study designs were examined. From published means and standard deviations for PD after therapy, odds ratios for the clinically relevant cut-off values were calculated using a specific statistical approach.

Results

Meta-analyses were performed for the time points 3 and 6 month after mechanical therapy. Generally, a pronounced chance for pocket closure from 3 to 6 months of healing was shown. The administration of antibiotics resulted in a 3.55 and 4.43 fold higher probability of pocket closure after 3 and 6 months as compared to mechanical therapy alone. However, as the estimated risk for residual pockets > 5 mm was 0 for both groups, no odds ratio could be calculated for persistent needs for surgery. Generally, studies showed a moderate to high quality and large heterogeneity regarding treatment protocol, dose of antibiotic medication and maintenance.

Conclusion

With the performed statistical approach, a clear benefit in terms of an enhanced chance for pocket closure by co-administration of the combination of amoxicillin and metronidazole as an adjunct to non-surgical mechanical periodontal therapy has been shown. However, data calculation failed to show a benefit regarding the possible avoidance of surgical interventions.

Peer Review reports

Background

Periodontitis is a widespread inflammatory disease of the tooth-supporting soft and hard tissues [13] with an intermittent destruction process. It progresses either chronically or aggressively [4], but in either case, bacterial involvement in biofilms is regarded as the primary etiologic factor for both disease initiation and progression [5, 6]. Accordingly, the pivotal aim of cause-related periodontal therapy is based on the removal of the pathogenic microbial challenge and the successful prevention of its re-establishment in the ecological niches [7]. Clinically, this is achieved by mechanical debridement using scalers, curettes and/or ultrasonic instruments along with proper oral hygiene instruction [8, 9]. In this context, however, a complete root surface cleaning has been shown to be an unrealistic aim: Especially in pockets exceeding a depth of 6 mm, a perfect debridement is impossible - even when performed by experienced operators [10, 11]. Despite these technical limitations, relevant outcome parameters like depth and number of pockets can be significantly reduced and maintained irrespective of the initial probing depth [12, 13]. However, in many situations periodontitis is not completely resolved by non-surgical mechanical means alone [14], especially in difficult to clean areas such as multi-rooted teeth and complex bone defect configurations [15].

Thus, the use of antimicrobials is a viable approach to improve the clinical outcomes. The adjunctive administration of systemic antibiotics for instance has been shown to offer special healing benefits to improve the mechanical debridement in critical sites [16]. In addition, periopathogenic bacteria are known to colonize not only subgingival tooth surfaces but also hide in oral niches like deep plications of the tongue, crypts of the palatopharyngeal tonsils or the inner buccal mucosa and its recesses, where they are mostly out of the reach of mechanical treatment [17, 18]. Noteworthy, some bacteria were even shown to invade periodontal soft tissue cells [1921], where they remain inaccessible for conventional mechanical debridement as well. Therefore, antibiotic therapy has gained a long tradition in periodontitis therapy [22]. However, well-controlled studies are limited to specific agents [23], among which, amoxicillin, metronidazole and their combination being the most frequently investigated antibiotics [24]. To date, a considerable number of studies have consistently shown a superiority of the systemic administration of these agents together with scaling and root planning (SRP), mainly in terms of probing pocket depths (PPD), clinical attachment levels (CAL) and changes as compared to SRP alone [24]. However, the problem of adverse side-effects and especially a seemingly ever increasing risk of bacterial resistance [25] urge clinicians to balance risks and benefits well with each individual patient.

Among parameters for oral hygiene, marginal inflammation and gingival recession, periodontal pocket depth (PPD) and clinical attachment loss (CAL) are still the most important surrogate parameters for clinical changes. Whereas CAL indicates the amount of periodontal destruction that will not necessarily be recovered in most cases with successful periodontal treatments, PPD is the parameter that should improve significantly during therapy. As PPD values up to 3 mm are regarded as being compatible with periodontal health, pockets exceeding 5 or 6 mm might not align with immediate treatment success or long-term stability. As these pockets show a significantly enhanced risk for further bacterial regrowth and attachment loss [26], they constitute an indication for additional – in most cases surgical - treatments. This fact is well reflected in the cut-off values for pocket depths of the Community Periodontal Treatment Index of Treatment Needs (CPITN) and the Periodontal Screening Record (PTR) [27, 28]. hoo.de > ly dation section tge language t in its te added. the phrase into. “ text as follows: ults in enhanced heterogeneit.

Following the guidelines for the conduction of the respective studies, systematic reviews with meta-analyses present differences of various treatment modalities expressed as means and standard deviations of the above-mentioned outcome parameters (e.g. PPD and/or CAL) in millimeters [2931]. Despite being statistically flawless, this mode of data presentation renders it difficult for clinicians and patients to estimate the clinical benefit in terms of an adjunctive treatment [32], as direct information on the degree of clinical success rate is not provided. Regarding a clinically applicable success estimation after periodontal treatment, the reduction of the periodontal pocket depth on a physiologic level of up to 3 mm, i.e. the clinical pocket closure, remains the most important end parameter. Beyond that, a further distinction between sites with moderately enhanced pocket depths that might remain stable over long time periods and those, which most probably need further invasive therapy, seems reasonable [26]. Thus, distinct cut-off values of ≤ 3 mm and ≤ 6 mm PPD might constitute important landmarks to clinicians and patients for every day decision-making.

Therefore, it was the aim of the present study to conduct a meta-analysis based on data of the existing literature on combined administration of amoxicillin and metronidazole as an adjunct to SRP, calculating the probability of clinical success by using these relevant cut-off values of 3 an 5 mm PPD to provide estimated for pocket closure and avoidance of surgery after scaling and root planing with systemic antibiotics.

Methods

This study was planned and conducted in accordance to the PRISMA guidelines for systematic reviews [29]. Modifications were made with regard to the study specific presentation of the outcomes expressed as means and standard deviations instead of estimated probability for the cut-off values.

The focused question according to the PICO criteria was:

“What is the outcome after non-surgical subgingival debridement with or without systemic administration using a combination of amoxicillin and metronidazole in healthy humans with chronic or aggressive periodontitis in terms of the estimated odds ratio for pocket closure (i.e. PPD ≤ 3 mm) or avoidance of surgery (i.e. PPD ≤ 5 mm)?”

A meta-analysis was conducted for data at 3 and 6 month after intervention.

Search strategy

A literature search up to June 2013 was conducted in the US National Library of Medicine (PubMed), the Exerpta Medical Database (Embase) and the Cochrane Central Register of Controlled trials (CENTRAL) using the search terms and combinations presented in Figure 1. After title and abstract screening, an additional hand search was performed in the reference lists of all full texts of interest and the index of contents of Journal of Clinical Periodontology, Journal of Periodontal Research and Journal of Periodontology. The search was conducted without language restriction. The literature search was performed by two independent reviewers (Kolakovic and Sahrmann). In case of discrepancies, study exclusion was determined after discussion. The search strategy is depicted in Figure 2.

Figure 1
figure1

Search items for the electronic literature search. MeSH – Mdical Subject Headings, TIAB – Title and Abstract.

Figure 2
figure2

Screening strategy performed by two independent reviewers. vWC – vanWinkelhoff Cocktail.

Eligibility criteria

In order to include data from studies of highest quality, only randomized controlled clinical trials were considered. Studies comparing the clinical outcomes of non-surgical periodontal treatment with and without adjunctive systemic antibiotic therapy focussing on the combination of amoxicillin and metronidazole, in otherwise healthy patients were included. Studies had to report data for periodontal probing depths after a time interval of at least 3 months after treatment, presented as means and standard deviations, which displayed normal data distribution. Studies on patients with known diseases or drug intake that potentially affects progression and therapy of periodontitis (diabetes, immunosuppressive medication etc.) were excluded. In order not to exclude an entity that is often specifically treated with a concomitant antibiotic medication smokers were not excluded.

Assessment of heterogeneity

To assess the comparability of the selected studies, data on diagnosis, patient populations, exclusion criteria, treatment protocols including pre-treatment, interventions and maintenance protocols of each study were extracted.

Quality assessment

To estimate the potential bias of the different studies included, the described method of randomization, the concealment strategy of the allocation and the blinding of the operator performing the clinical examination were assessed.

Statistical analysis

From each study, we extracted the number of participants and the mean pocket depth and standard deviation at the follow-up examination(s). If not exactly described in the respective statistical methodology section in the original paper, we assumed that the pocket depths were normally distributed if they were presented as mean and standard deviation. Based on available data sets, the probability of clinical success, expressed as the proportion of pockets < 3 mm, and the proportion of persisting pockets > 3 mm and > 5 mm, respectively, using the method proposed by Hauri and co-workers [32] was determined. For this purpose, the odds ratios (OR) and their 95% confidence intervals from the derived event rates in experimental and control group for each of the studies were calculated. For pooling of these ORs a fixed effects meta-analysis model was used. All analyses were performed with R, a free software environment for statistical computing and graphics [33].

Results

Study selection

The electronic literature search provided 1603 potentially includable studies. Based on titles and abstracts, 1537 of these were excluded (93% agreement between reviewers prior to discussion). Based on the full text assessment further 40 studies were excluded due to administration of antibiotics other than the combination of interest, data presentation without means and standard deviations or inadequate intervention in either test or control group (see Figure 2 and Table 1[3458]). In case of missing clinical data or unsuitable data presentation the corresponding authors were contacted via electronic mail requesting further information, [59, 60]. If no reply was received within 12 weeks, the respective study had to be excluded. The remaining studies could not be included into the meta-analysis due to their individual time points of data evaluation.

Table 1 Excluded studies

Study heterogeneity and study characteristics

In some studies smokers were excluded [6164], one study included only smokers [65] while others [6675] included both or even did not report on the smoking status of their study population.

Generally, periodontitis cases were classified as generalized chronic or aggressive periodontitis or were not further classified. Not every study reported explicitly to what extent oral hygiene instructions were given before treatment. Frequency and method of supragingival cleaning remains unclear in some studies [67, 69, 70, 7375]. Test- and control interventions were performed either as full mouth or quadrant-wise treatments with either hand instruments, ultrasonic devices or both. All studies used local anesthesia during subgingival cleaning. Prescribed antibiotics varied in concentration (375–500 mg for amoxicillin and 250/400/500 mg for metronidazole, three times a day each) and the period of intake (7, 10 or 14 days). Different modes of controlling the drug adherence were described. The post-interventional care varied in terms of the use of antiseptic solutions like chlorhexidine of different concentrations and pharmacological forms (gel, mouth washes) and concentrations (0.1/0.12/0.2/1.0%). The periods of investigation varied from 3 to 24 months (Table 2).

Table 2 Study description

Quality assessment

The quality assessment is presented in Table 3. If the method of randomization, concealment or the blinding of the examiner was clearly described, the quality was rated as “+” if it was claimed that randomization, concealment or the blinding was performed but no information about the mode of performance was provided the rating was “(+)” and if no concealment or blinding was stated, the rating was “–”. Based on this rating, study quality was assessed as moderate to high.

Table 3 Quality assessment

Study outcomes

For the re-evaluation time points we performed two meta-analyses, one at 3 months after treatment and one after 6 month, which included 10 and 7 studies with a total of 521 and 448 patients, respectively.The meta-analyses revealed that the use of the combination of amoxicillin and metronidazole together with SRP increased the chance of pocket closure by a factor of 3.55 three month after the therapy (Figure 3) and a pronounced 4.43 fold chance six month after the treatment (Figure 4).

Figure 3
figure3

Meta-analysis of the chance for pocket closure after 3 months. OR – odds ratio, 95-CI – 95% confidence intervall, w – weight, p – level of significance.

Figure 4
figure4

Meta-analysis of the chance for pocket closure after 6 months. OR – odds ratio, 95-CI – 95% confidence intervall, w – weight, p – level of significance.

We found that it was not possible to calculate the risk estimation for residual pockets exceeding 5 mm, as there was an estimated risk for residual pockets over 5 mm of 0 for both treatment types, which rendered the comparative calculation impossible.

The estimated percentage for pertinent pockets exceeding 3 and 5 mm for the additional use of antibiotics and for SRP alone is presented in Table 4a (at time point 3 months) and b (at time point 6 months).

Table 4 Percent of persisting pockets deeper than 3 mm and 5 mm

For two additional studies [62, 71] with data given for both the means and standard deviations and the exact proportion of residual pockets, we performed the same estimation like for the included studies in order to re-validate the statistical model (Table 5). The comparison of published and calculated ratios show a qualitative accordance. However, some subgroups showed considerable differences in size.

Table 5 Comparison of published and calculated OR for the use of antibiotics for studies providing both means and standard deviations and percentages of residual pockets

Discussion

This study aimed to estimate the chance of pocket closure or avoidance of surgical therapy after non-surgical periodontal treatment comparing the treatment with and without the additional use of the combination of the amoxicillin and metronidazole. Other than in conventional systematic reviews and different to the data presentation recommended by the PRISMA statement [76], this review did not present the differences by means and standard deviations, but estimated the likelihood for the attainment of clinical relevant surrogate parameters. We believe that this kind of data presentation provides easier and clinically more relevant interpretations of the clinical effectiveness, as in periodontal treatment the main target is the reduction of pockets below a cut-off pocket depth of less than 3 mm or not exceeding 5 mm [26]: The first benchmark indicates that the pockets are “closed” with no further treatment needs, whereas the second benchmark indicates the avoidance of specific needs for a surgical intervention, which is classically still indicated if pockets of 6 mm depth and deeper persist after treatment due to their significantly enhanced risk for disease recurrence [26].

This study clearly elucidated an enhanced chance for pocket closure when antibiotics were used in combination with mechanical root surface debridement. On the other hand, the calculations could not be performed for the case of a cut-off value > 5 mm. This implied that the statistical model indicated a 100% elimination of pockets > 5 mm for both the treatment with and without the use of antibiotics. This fact depicts a shortcoming of the performed statistical estimation, as the single studies in fact reported isolated residual pockets.

In all the included studies, we assumed a normal distribution of the data [77]. With relatively small case numbers, this expectation might have distorted the calculated results to some extent. However, the effect of possible statistical misclassification was likely to be similar in test and control group due to the randomization of the treatment allocation of the studies, thus limiting the disturbing bias again.

We tried to verify the adaptability of the statistical model using the calculation in studies that provided both, means and standard deviations and the exact distribution of residual pockets of either > 3 mm or > 5 mm depth. In the data of one study group [62, 78] we found a good correlation of true and calculated results. However, in another the true and estimated values varied to a greater extent [71], despite the fact that important factors such as sample size were comparable.

The calculation model has been previously published and more studies using this analysis methodology have been demanded [32]. With the present data, its applicability can be better understood and its limitation to studies with higher numbers of participants appears recommendable. In conclusion, the data presentation of the exact distribution of the pocket depths over 3 and 5 mm – as already presented in the actual literature – should be provided in future studies as it was done in the classical studies as well. However, such a request needs time to push through and as long as this claim is not generally implemented, the proposed statistical model offers a useful alternative method to combine and compare study results in such a way.

The pronounced effect of the antibiotics during healing after the first three months as compared to healing after SRP alone is well reflected well in our analysis: For pocket closure, there is an enhanced chance after 6 month if antibiotics had been used. This finding is in accordance with the existing literature [30, 79, 80].

A large heterogeneity existed for the included data: Smoking status, diagnosis of aggressive or chronic periodontitis and the detailed treatment scheme used in the studies showed substantial variations. With the cumulative analysis there was a certain risk of comparing apples with oranges. However, this approach offered the possibility to generate a universal conclusion on the antibiotic treatment of periodontitis, regardless of which patients were treated with which protocol. Furthermore, and another limitation of our approach, we could not include important studies assessing the issue of interest because of the way on which their data was presented: Several authors presented their data well and even with the similar aim to refer to distributions of specific benchmark values, but unfortunately other cut-off values than ours were chosen, which rendered a comparison impossible.

With 10 and 7 included studies for the time points 3 and 6 months after treatment, respectively, only a relatively small number of studies dealing with the issue of antibiotics in periodontitis treatment could be included. Zandbergen et al. assessed a body of 24 studies in a classic review [30]. However, aiming to perform a meta-analysis they could only calculate the overall change of PD and CAL for SRP in combination with antibiotics. Neither a direct comparison to the treatment without antibiotics, nor an estimate of the treatment success in terms of pocket closure or avoidance of surgical therapy was possible in their review. These aspects, however, are important to both the practitioner and the patient.

The benefits of antibiotic treatment always have always to be balanced against their possible adverse reactions. For amoxicillin allergic skin reactions, joint swelling and – in few cases – anaphylactic reactions are well documented [81]. Metronidazole has frequently been reported to cause – among other discomforts and indispositions - nausea, diarrhea and headache [82]. The dimension of the potential risk of causing resistant strains against these antibiotics must also be kept in mind, even if the discussion about this issue is controversial in the current literature [25, 82, 83]. For the clinician a clear prediction of the benefits of adjunctive antibiotic therapy in therms of residual treatment needs after non-surgical treatment might be an easier and better tool for the consideration of a possible antibiotic prescription than rather abstract means and standard deviations as predominantly presented in conventional reviews.

Conclusion

Using a distribution based statistical approach, it was shown that there is a clear benefit in terms of an enhanced chance for pocket closure by co-administration of the combination of amoxicillin and metronidazole as adjunct to non-surgical mechanical periodontal therapy. However, based on the currently available data a potential benefit in terms of the possible avoidance of surgical interventions could not be delineated.

Appendix

The following formula for the calculation of the probabilities P(X”x) for clinical success, ie, for pockets >3 mm was used:

F(X)(x) describes the cumulative distribution function, the mean, the standard deviation and x the cutoff value, eg 3 mm or 5 mm.

For the expression:

One can determine the probabilities by consulting normal distribution tables [58]. stands for the distribution function of the standard normal distribution. The probability values in the Tables published by Stahel are only valid for standard normal distribution. For example, for a group of nine patients, the mean pocket depth at followup is 3.53 mm with a standard deviation of 0.62. Therefore, for:

We get ((3.00 - 3.53)/0.62) = -0.85. The probability for pockets ≤ 3 mm is 0.20, as derived from the Table in Stahel [58]. Hence, the number of patients with pockets ″Accordingly, the number of patients with pockets ≤ 3 mm is 9 × 0.20 and the number of patients with pockets >3 mm is 0.80×9 [32].

References

  1. 1.

    Loe H: Principles of aetiology and pathogenesis governing the treatment of periodontal disease. Int Dent J. 1983, 33: 119-126.

    PubMed  Google Scholar 

  2. 2.

    Oliver RC, Brown LJ, Loe H: Periodontal diseases in the United States population. J Periodontol. 1998, 69: 269-278. 10.1902/jop.1998.69.2.269.

    Article  PubMed  Google Scholar 

  3. 3.

    Albandar JM, Rams TE: Global epidemiology of periodontal diseases: an overview. Periodontol 2000. 2002, 29: 7-10. 10.1034/j.1600-0757.2002.290101.x.

    Article  PubMed  Google Scholar 

  4. 4.

    Heitz-Mayfield LJ, Lang NP: Comparative biology of chronic and aggressive periodontitis vs. peri-implantitis. Periodontol 2000. 2010, 53: 167-181. 10.1111/j.1600-0757.2010.00348.x.

    Article  PubMed  Google Scholar 

  5. 5.

    Socransky SS: Microbiology of periodontal disease – present status and future considerations. J Periodontol. 1977, 48: 497-504. 10.1902/jop.1977.48.9.497.

    Article  PubMed  Google Scholar 

  6. 6.

    Periodontics AAPWWi: Consensus report. Periodontal diseases: pathogenesis and microbial factors. Ann Periodontol. 1996, 1: 926-932.

    Article  Google Scholar 

  7. 7.

    Badersten A, Nilveus R, Egelberg J: Effect of nonsurgical periodontal therapy. I. Moderately advanced periodontitis. J Clin Periodontol. 1981, 8: 57-72. 10.1111/j.1600-051X.1981.tb02024.x.

    Article  PubMed  Google Scholar 

  8. 8.

    Magnusson I, Lindhe J, Yoneyama T, Liljenberg B: Recolonization of a subgingival microbiota following scaling in deep pockets. J Clin Periodontol. 1984, 11: 193-207. 10.1111/j.1600-051X.1984.tb01323.x.

    Article  PubMed  Google Scholar 

  9. 9.

    Westfelt E, Rylander H, Dahlen G, Lindhe J: The effect of supragingival plaque control on the progression of advanced periodontal disease. J Clin Periodontol. 1998, 25: 536-541. 10.1111/j.1600-051X.1998.tb02484.x.

    Article  PubMed  Google Scholar 

  10. 10.

    Caffesse RG, Sweeney PL, Smith BA: Scaling and root planing with and without periodontal flap surgery. J Clin Periodontol. 1986, 13: 205-210. 10.1111/j.1600-051X.1986.tb01461.x.

    Article  PubMed  Google Scholar 

  11. 11.

    Brayer WK, Mellonig JT, Dunlap RM, Marinak KW, Carson RE: Scaling and root planing effectiveness: the effect of root surface access and operator experience. J Periodontol. 1989, 60: 67-72. 10.1902/jop.1989.60.1.67.

    Article  PubMed  Google Scholar 

  12. 12.

    Hirschfeld L, Wasserman B: A long-term survey of tooth loss in 600 treated periodontal patients. J Periodontol. 1978, 49: 225-237. 10.1902/jop.1978.49.5.225.

    Article  PubMed  Google Scholar 

  13. 13.

    Adriaens PA, Adriaens LM: Effects of nonsurgical periodontal therapy on hard and soft tissues. Periodontol 2000. 2004, 36: 121-145. 10.1111/j.1600-0757.2004.03676.x.

    Article  PubMed  Google Scholar 

  14. 14.

    Morrison EC, Ramfjord SP, Hill RW: Short-term effects of initial, nonsurgical periodontal treatment (hygienic phase). J Clin Periodontol. 1980, 7: 199-211. 10.1111/j.1600-051X.1980.tb01963.x.

    Article  PubMed  Google Scholar 

  15. 15.

    Fleischer HC, Mellonig JT, Brayer WK, Gray JL, Barnett JD: Scaling and root planing efficacy in multirooted teeth. J Periodontol. 1989, 60: 402-409. 10.1902/jop.1989.60.7.402.

    Article  PubMed  Google Scholar 

  16. 16.

    Mombelli A, Samaranayake LP: Topical and systemic antibiotics in the management of periodontal diseases. Int Dent J. 2004, 54: 3-14. 10.1111/j.1875-595X.2004.tb00246.x.

    Article  PubMed  Google Scholar 

  17. 17.

    Quirynen M, De Soete M, Dierickx K, van Steenberghe D: The intra-oral translocation of periodontopathogens jeopardises the outcome of periodontal therapy. A review of the literature. J Clin Periodontol. 2001, 28: 499-507. 10.1034/j.1600-051x.2001.028006499.x.

    Article  PubMed  Google Scholar 

  18. 18.

    Muller HP, Heinecke A, Fuhrmann A, Eger T, Zoller L: Intraoral distribution of Actinobacillus actinomycetemcomitans in young adults with minimal periodontal disease. J Periodontal Res. 2001, 36: 114-123. 10.1034/j.1600-0765.2001.360208.x.

    Article  PubMed  Google Scholar 

  19. 19.

    Rudney JD, Chen R, Sedgewick GJ: Intracellular Actinobacillus actinomycetemcomitans and Porphyromonas gingivalis in buccal epithelial cells collected from human subjects. Infect Immun. 2001, 69: 2700-2707. 10.1128/IAI.69.4.2700-2707.2001.

    Article  PubMed  PubMed Central  Google Scholar 

  20. 20.

    Blix IJ, Hars R, Preus HR, Helgeland K: Entrance of Actinobacillus actinomycetemcomitans into HEp-2 cells in vitro. J Periodontol. 1992, 63: 723-728. 10.1902/jop.1992.63.9.723.

    Article  PubMed  Google Scholar 

  21. 21.

    Sreenivasan PK, Meyer DH, Fives-Taylor PM: Requirements for invasion of epithelial cells by Actinobacillus actinomycetemcomitans. Infect Immun. 1993, 61: 1239-1245.

    PubMed  PubMed Central  Google Scholar 

  22. 22.

    OSTRANDER FD: Vitamins, sulfonamides and antibiotics in periodontal therapy. J Am Dent Assoc. 1948, 37: 279-288. 10.14219/jada.archive.1948.0193.

    Article  PubMed  Google Scholar 

  23. 23.

    Slots J, Ting M: Systemic antibiotics in the treatment of periodontal disease. Periodontol 2000. 2002, 28: 106-176. 10.1034/j.1600-0757.2002.280106.x.

    Article  PubMed  Google Scholar 

  24. 24.

    Mombelli A, Cionca N, Almaghlouth A, Decaillet F, Courvoisier DS, Giannopoulou C: Are there specific benefits of amoxicillin plus metronidazole in Aggregatibacter actinomycetemcomitans-associated periodontitis? Double-masked, randomized clinical trial of efficacy and safety. J Periodontol. 2013, 84: 715-724. 10.1902/jop.2012.120281.

    Article  PubMed  Google Scholar 

  25. 25.

    Veloo AC, Seme K, Raangs E, Rurenga P, Singadji Z, Wekema-Mulder G, van Winkelhoff AJ: Antibiotic susceptibility profiles of oral pathogens. Int J Antimicrob Agents. 2012, 40: 450-454. 10.1016/j.ijantimicag.2012.07.004.

    Article  PubMed  Google Scholar 

  26. 26.

    Matuliene G, Studer R, Lang NP, Schmidlin K, Pjetursson BE, Salvi GE, Bragger U, Zwahlen M: Significance of Periodontal Risk Assessment in the recurrence of periodontitis and tooth loss. J Clin Periodontol. 2010, 37: 191-199. 10.1111/j.1600-051X.2009.01508.x.

    Article  PubMed  Google Scholar 

  27. 27.

    Ainamo J, Barmes D, Beagrie G, Cutress T, Martin J, Sardo-Infirri J: Development of the World Health Organization (WHO) community periodontal index of treatment needs (CPITN). Int Dent J. 1982, 32: 281-291.

    PubMed  Google Scholar 

  28. 28.

    Nasi JH: Background to, and implementation of, the Periodontal Screening and Recording (PSR) procedure in the USA. Int Dent J. 1994, 44: 585-588.

    PubMed  Google Scholar 

  29. 29.

    Moher D, Liberati A, Tetzlaff J, Altman DG: Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. BMJ. 2009, 339: b2535-10.1136/bmj.b2535.

    Article  PubMed  PubMed Central  Google Scholar 

  30. 30.

    Zandbergen D, Slot DE, Cobb CM, Van der Weijden FA: The clinical effect of scaling and root planing and the concomitant administration of systemic amoxicillin and metronidazole: a systematic review. J Periodontol. 2013, 84: 332-351. 10.1902/jop.2012.120040.

    Article  PubMed  Google Scholar 

  31. 31.

    Sgolastra F, Gatto R, Petrucci A, Monaco A: Effectiveness of systemic amoxicillin/metronidazole as adjunctive therapy to scaling and root planing in the treatment of chronic periodontitis: a systematic review and meta-analysis. J Periodontol. 2012, 83: 1257-1269. 10.1902/jop.2012.110625.

    Article  PubMed  Google Scholar 

  32. 32.

    Hauri D, Schmidlin PR, Puhan MA: Development of an easily interpretable presentation format for meta-analyses in periodontal surgery. Evid Based Dent. 2008, 9: 89-90. 10.1038/sj.ebd.6400604.

    Article  PubMed  Google Scholar 

  33. 33.

    RCT: R: A language and environment for statistical computing. 2013, Vienna, Austria: R Foundation for Statistical Computing, URL. http://wwwR-project.org, 3-900051-07-0

    Google Scholar 

  34. 34.

    Akincibay H, Orsal SO, Sengun D, Tozum TF: Systemic administration of doxycycline versus metronidazole plus amoxicillin in the treatment of localized aggressive periodontitis: a clinical and microbiologic study. Quintessence Int. 2008, 39: e33-9.

    PubMed  Google Scholar 

  35. 35.

    Carvalho LH, D'Avila GB, Leao A, Goncalves C, 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 II–microbiological results. J Clin Periodontol. 2005, 32: 406-411. 10.1111/j.1600-051X.2005.00720.x.

    Article  PubMed  Google Scholar 

  36. 36.

    Cionca N, Giannopoulou C, Ugolotti G, Mombelli A: Microbiologic testing and outcomes of full-mouth scaling and root planing with or without amoxicillin/metronidazole in chronic periodontitis. J Periodontol. 2010, 81: 15-23. 10.1902/jop.2009.090390.

    Article  PubMed  Google Scholar 

  37. 37.

    Ehmke B, Beikler T, Haubitz I, Karch H, Flemmig TF: Multifactorial assessment of predictors for prevention of periodontal disease progression. Clin Oral Investig. 2003, 7: 217-221. 10.1007/s00784-003-0227-2.

    Article  PubMed  Google Scholar 

  38. 38.

    Ehmke B, Moter A, Beikler T, Milian E, Flemmig TF: Adjunctive antimicrobial therapy of periodontitis: long-term effects on disease progression and oral colonization. J Periodontol. 2005, 76: 749-759. 10.1902/jop.2005.76.5.749.

    Article  PubMed  Google Scholar 

  39. 39.

    Eickholz P, Siegelin Y, Scharf S, Schacher B, Oremek GM, Sauer-Eppel H, Schubert R, Wohlfeil M: Non-surgical periodontal therapy decreases serum elastase levels in aggressive but not in chronic periodontitis. J Clin Periodontol. 2013, 40: 327-333. 10.1111/jcpe.12076.

    Article  PubMed  Google Scholar 

  40. 40.

    Eisenberg L, Suchow R, Coles RS, Deasy MJ: The effects of metronidazole administration on clinical and microbiologic parameters of periodontal disease. Clin Prev Dent. 1991, 13: 28-34.

    PubMed  Google Scholar 

  41. 41.

    Feres M, Soares GM, Mendes JA, Silva MP, Faveri M, Teles R, Socransky SS, Figueiredo LC: Metronidazole alone or with amoxicillin as adjuncts to non-surgical treatment of chronic periodontitis: a 1-year double-blinded, placebo-controlled, randomized clinical trial. J Clin Periodontol. 2012, 39: 1149-1158. 10.1111/jcpe.12004.

    Article  PubMed  Google Scholar 

  42. 42.

    Flemmig TF, Milian E, Karch H, Klaiber B: Differential clinical treatment outcome after systemic metronidazole and amoxicillin in patients harboring Actinobacillus actinomycetemcomitans and/or Porphyromonas gingivalis. J Clin Periodontol. 1998, 25: 380-387. 10.1111/j.1600-051X.1998.tb02459.x.

    Article  PubMed  Google Scholar 

  43. 43.

    Haffajee AD, Patel M, Socransky SS: Microbiological changes associated with four different periodontal therapies for the treatment of chronic periodontitis. Oral Microbiol Immunol. 2008, 23: 148-157. 10.1111/j.1399-302X.2007.00403.x.

    Article  PubMed  Google Scholar 

  44. 44.

    Hartmann J, Muller HP, Flores-de-Jacoby L: Systemic metronidazole therapy and/or subgingival scaling and root planing. II. Development of clinical parameters in relation to the changes in the composition of the associated subgingival microflora. Dtsch Zahnarztl Z. 1986, 41: 579-584.

    PubMed  Google Scholar 

  45. 45.

    Hernandez E, Castella R: Metronidazol en el tratamiento de la enfermedad periodontal. Practica Odontologica. 1987, 8: 34-38.

    Google Scholar 

  46. 46.

    Jenkins WM, MacFarlane TW, Gilmour WH, Ramsay I, MacKenzie D: Systemic metronidazole in the treatment of periodontitis. J Clin Periodontol. 1989, 16: 443-450. 10.1111/j.1600-051X.1989.tb01673.x.

    Article  PubMed  Google Scholar 

  47. 47.

    Joyston-Bechal S, Smales FC, Duckworth R: Effect of metronidazole on chronic periodontal disease in subjects using a topically applied chlorhexidine gel. J Clin Periodontol. 1984, 11: 53-62. 10.1111/j.1600-051X.1984.tb01308.x.

    Article  PubMed  Google Scholar 

  48. 48.

    Joyston-Bechal S, Smales FC, Duckworth R: A follow-up study 3 years after metronidazole therapy for chronic periodontal disease. J Clin Periodontol. 1986, 13: 944-949. 10.1111/j.1600-051X.1986.tb01432.x.

    Article  PubMed  Google Scholar 

  49. 49.

    Lindhe J, Westfelt E, Nyman S, Socransky SS, Heijl L, Bratthall G: Healing following surgical/non-surgical treatment of periodontal disease. A clinical study. J Clin Periodontol. 1982, 9: 115-128. 10.1111/j.1600-051X.1982.tb01227.x.

    Article  PubMed  Google Scholar 

  50. 50.

    Loesche WJ, Schmidt E, Smith BA, Caffessee R, Stoll J: Metronidazole therapy for periodontitis. J Periodontal Res. 1987, 22: 224-226. 10.1111/j.1600-0765.1987.tb01574.x.

    Article  PubMed  Google Scholar 

  51. 51.

    Loesche WJ, Giordano JR, Hujoel P, Schwarcz J, Smith BA: Metronidazole in periodontitis: reduced need for surgery. J Clin Periodontol. 1992, 19: 103-112. 10.1111/j.1600-051X.1992.tb00448.x.

    Article  PubMed  Google Scholar 

  52. 52.

    Loesche WJ, Grossman N, Giordano J: Metronidazole in periodontitis (IV). The effect of patient compliance on treatment parameters. J Clin Periodontol. 1993, 20: 96-104. 10.1111/j.1600-051X.1993.tb00336.x.

    Article  PubMed  Google Scholar 

  53. 53.

    Lu RF, Xu L, Feng XH, Meng HX: [Short term effect of combined use of amoxicillin and metronidazole at different time of non-surgical periodontal treatment for aggressive periodontitis]. Zhonghua Kou Qiang Yi Xue Za Zhi. 2012, 47: 666-670.

    PubMed  Google Scholar 

  54. 54.

    Lundstrom A, Johansson LA, Hamp SE: Effect of combined systemic antimicrobial therapy and mechanical plaque control in patients with recurrent periodontal disease. J Clin Periodontol. 1984, 11: 321-330. 10.1111/j.1600-051X.1984.tb01328.x.

    Article  PubMed  Google Scholar 

  55. 55.

    Mombelli A, Brochut P, Plagnat D, Casagni F, Giannopoulou C: Enamel matrix proteins and systemic antibiotics as adjuncts to non-surgical periodontal treatment: clinical effects. J Clin Periodontol. 2005, 32: 225-230. 10.1111/j.1600-051X.2005.00664.x.

    Article  PubMed  Google Scholar 

  56. 56.

    Sigusch B, Pfister W, Klinger G, Glockmann E: [Adjuvant antibiotic therapy as a 2-step treatment concept in early-onset periodontitis: a strategy for eradication of bacteria that cause periodontitis]. Dtsch Med Wochenschr. 2000, 125: 1186-1191. 10.1055/s-2000-7699.

    Article  PubMed  Google Scholar 

  57. 57.

    Sigusch B, Beier M, Klinger G, Pfister W, Glockmann E: A 2-step non-surgical procedure and systemic antibiotics in the treatment of rapidly progressive periodontitis. J Periodontol. 2001, 72: 275-283. 10.1902/jop.2001.72.3.275.

    Article  PubMed  Google Scholar 

  58. 58.

    Stahel WA: Statistische Datenanalyse. Eine Einführung für Naturwissenschaftler. 2002, Vieweg, Braunschweig: ᅟ, 4th edition: ch 4.9

    Google Scholar 

  59. 59.

    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. 10.1111/j.1600-051X.2005.00814.x.

    Article  PubMed  Google Scholar 

  60. 60.

    Loesche WJ, Schmidt E, Smith BA, Morrison EC, Caffesse R, Hujoel PP: Effects of metronidazole on periodontal treatment needs. J Periodontol. 1991, 62: 247-257. 10.1902/jop.1991.62.4.247.

    Article  PubMed  Google Scholar 

  61. 61.

    Aimetti M, Romano F, Guzzi N, Carnevale G: Full-mouth disinfection and systemic antimicrobial therapy in generalized aggressive periodontitis: a randomized, placebo-controlled trial. J Clin Periodontol. 2012, 39: 284-294. 10.1111/j.1600-051X.2011.01795.x.

    Article  PubMed  Google Scholar 

  62. 62.

    Mestnik MJ, Feres M, Figueiredo LC, Duarte PM, Lira EA, Faveri M: Short-term benefits of the adjunctive use of metronidazole plus amoxicillin in the microbial profile and in the clinical parameters of subjects with generalized aggressive periodontitis. J Clin Periodontol. 2010, 37: 353-365. 10.1111/j.1600-051X.2010.01538.x.

    Article  PubMed  Google Scholar 

  63. 63.

    Moeintaghavi A, Talebi-ardakani MR, Haerian-ardakani A, Zandi H, Taghipour S, Fallahzadeh H, Pakzad A, Fahami N: Adjunctive effects of systemic amoxicillin and metronidazole with scaling and root planing: a randomized, placebo controlled clinical trial. J Contemp Dent Pract. 2007, 8: 51-59.

    PubMed  Google Scholar 

  64. 64.

    Ribeiro Edel P, Bittencourt S, Zanin IC, Bovi Ambrosano GM, Sallum EA, Nociti FH, Goncalves RB, Casati MZ: Full-mouth ultrasonic debridement associated with amoxicillin and metronidazole in the treatment of severe chronic periodontitis. J Periodontol. 2009, 80: 1254-1264. 10.1902/jop.2009.080403.

    Article  PubMed  Google Scholar 

  65. 65.

    Matarazzo F, Figueiredo LC, Cruz SE, Faveri M, Feres M: Clinical and microbiological benefits of systemic metronidazole and amoxicillin in the treatment of smokers with chronic periodontitis: a randomized placebo-controlled study. J Clin Periodontol. 2008, 35: 885-896. 10.1111/j.1600-051X.2008.01304.x.

    Article  PubMed  Google Scholar 

  66. 66.

    Berglundh T, Krok L, Liljenberg B, Westfelt E, Serino G, Lindhe J: The use of metronidazole and amoxicillin in the treatment of advanced periodontal disease. A prospective, controlled clinical trial. J Clin Periodontol. 1998, 25: 354-362. 10.1111/j.1600-051X.1998.tb02455.x.

    Article  PubMed  Google Scholar 

  67. 67.

    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. 10.1111/j.1600-051X.2004.00605.x.

    Article  PubMed  Google Scholar 

  68. 68.

    Cionca N, Giannopoulou C, Ugolotti G, Mombelli A: Amoxicillin and metronidazole as an adjunct to full-mouth scaling and root planing of chronic periodontitis. J Periodontol. 2009, 80: 364-371. 10.1902/jop.2009.080540.

    Article  PubMed  Google Scholar 

  69. 69.

    Haffajee AD, Torresyap G, Socransky SS: Clinical changes following four different periodontal therapies for the treatment of chronic periodontitis: 1-year results. J Clin Periodontol. 2007, 34: 243-253. 10.1111/j.1600-051X.2006.01040.x.

    Article  PubMed  Google Scholar 

  70. 70.

    Heller D, Varela VM, Silva-Senem MX, Torres MC, Feres-Filho EJ, Colombo AP: Impact of systemic antimicrobials combined with anti-infective mechanical debridement on the microbiota of generalized aggressive periodontitis: a 6-month RCT. J Clin Periodontol. 2011, 38: 355-364. 10.1111/j.1600-051X.2011.01707.x.

    Article  PubMed  Google Scholar 

  71. 71.

    Rooney J, Wade WG, Sprague SV, Newcombe RG, Addy M: Adjunctive effects to non-surgical periodontal therapy of systemic metronidazole and amoxycillin alone and combined. A placebo controlled study. J Clin Periodontol. 2002, 29: 342-350. 10.1034/j.1600-051X.2002.290410.x.

    Article  PubMed  Google Scholar 

  72. 72.

    Soder B, Nedlich U, Jin LJ: Longitudinal effect of non-surgical treatment and systemic metronidazole for 1 week in smokers and non-smokers with refractory periodontitis: a 5-year study. J Periodontol. 1999, 70: 761-771. 10.1902/jop.1999.70.7.761.

    Article  PubMed  Google Scholar 

  73. 73.

    Winkel EG, van Winkelhoff AJ, Barendregt DS, van der Weijden GA, Timmerman MF, van der Velden U: Clinical and microbiological effects of initial periodontal therapy in conjunction with amoxicillin and clavulanic acid in patients with adult periodontitis. A randomised double-blind, placebo-controlled study. J Clin Periodontol. 1999, 26: 461-468. 10.1034/j.1600-051X.1999.260708.x.

    Article  PubMed  Google Scholar 

  74. 74.

    Winkel EG, Van Winkelhoff AJ, Timmerman MF, Van der Velden U, Van der Weijden GA: Amoxicillin plus metronidazole in the treatment of adult periodontitis patients. A double-blind placebo-controlled study. J Clin Periodontol. 2001, 28: 296-305. 10.1034/j.1600-051x.2001.028004296.x.

    Article  PubMed  Google Scholar 

  75. 75.

    Xajigeorgiou C, Sakellari D, Slini T, Baka A, Konstantinidis A: Clinical and microbiological effects of different antimicrobials on generalized aggressive periodontitis. J Clin Periodontol. 2006, 33: 254-264. 10.1111/j.1600-051X.2006.00905.x.

    Article  PubMed  Google Scholar 

  76. 76.

    Moher D, Cook DJ, Eastwood S, Olkin I, Rennie D, Stroup DF: Improving the quality of reports of meta-analyses of randomised controlled trials: the QUOROM statement. Quality of Reporting of Meta-analyses. Lancet. 1999, 354: 1896-1900. 10.1016/S0140-6736(99)04149-5.

    Article  PubMed  Google Scholar 

  77. 77.

    Schmidlin PR, Hauri D, Krahenmann MA, Puhan MA, Attin T: Residual pocket depth after periodontal regenerative procedures. Clinical relevance and interpretation of meta-analyses data. Schweiz Monatsschr Zahnmed. 2009, 119: 224-231.

    PubMed  Google Scholar 

  78. 78.

    Mestnik MJ, Feres M, Figueiredo LC, Soares G, Teles RP, Fermiano D, Duarte PM, Faveri M: The effects of adjunctive metronidazole plus amoxicillin in the treatment of generalized aggressive periodontitis: a 1-year double-blinded, placebo-controlled, randomized clinical trial. J Clin Periodontol. 2012, 39: 955-961. 10.1111/j.1600-051X.2012.01932.x.

    Article  PubMed  Google Scholar 

  79. 79.

    Kaner D, Christan C, Dietrich T, Bernimoulin JP, Kleber BM, Friedmann A: Timing affects the clinical outcome of adjunctive systemic antibiotic therapy for generalized aggressive periodontitis. J Periodontol. 2007, 78: 1201-1208. 10.1902/jop.2007.060437.

    Article  PubMed  Google Scholar 

  80. 80.

    Griffiths GS, Ayob R, Guerrero A, Nibali L, Suvan J, Moles DR, Tonetti MS: Amoxicillin and metronidazole as an adjunctive treatment in generalized aggressive periodontitis at initial therapy or re-treatment: a randomized controlled clinical trial. J Clin Periodontol. 2011, 38: 43-49. 10.1111/j.1600-051X.2010.01632.x.

    Article  PubMed  Google Scholar 

  81. 81.

    Anon: rescribing information. Amoxicillin Sandoz (amoxicillin). ᅟ, http://compendium.ch/mpro/mnr/15125/html/de (accessed March 2014)

    Google Scholar 

  82. 82.

    Mombelli A, Cionca N, Almaghlouth A: Does adjunctive antimicrobial therapy reduce the perceived need for periodontal surgery?. Periodontol 2000. 2011, 55: 205-216. 10.1111/j.1600-0757.2010.00356.x.

    Article  PubMed  Google Scholar 

  83. 83.

    Ardila CM, Granada MI, Guzman IC: Antibiotic resistance of subgingival species in chronic periodontitis patients. J Periodontal Res. 2010, 45: 557-563.

    PubMed  Google Scholar 

  84. 84.

    Giannopoulou C, Andersen E, Brochut P, Plagnat D, Mombelli A: Enamel matrix derivative and systemic antibiotics as adjuncts to non-surgical periodontal treatment: biologic response. J Periodontol. 2006, 77: 707-713. 10.1902/jop.2006.050166.

    Article  PubMed  Google Scholar 

  85. 85.

    Moreira RM, Feres-Filho EJ: Comparison between full-mouth scaling and root planing and quadrant-wise basic therapy of aggressive periodontitis: 6-month clinical results. J Periodontol. 2007, 78: 1683-1688. 10.1902/jop.2007.060354.

    Article  PubMed  Google Scholar 

  86. 86.

    Muller HP, Hartmann J, Flores-de-Jacoby L: Systemic metronidazole therapy and/or subgingival scaling with root planing. I. Clinical results. Dtsch Zahnarztl Z. 1986, 41: 573-578.

    PubMed  Google Scholar 

  87. 87.

    Noyan U, Yilmaz S, Kuru B, Kadir T, Acar O, Buget E: A clinical and microbiological evaluation of systemic and local metronidazole delivery in adult periodontitis patients. J Clin Periodontol. 1997, 24: 158-165. 10.1111/j.1600-051X.1997.tb00485.x.

    Article  PubMed  Google Scholar 

  88. 88.

    Palmer RM, Matthews JP, Wilson RF: Adjunctive systemic and locally delivered metronidazole in the treatment of periodontitis: a controlled clinical study. Br Dent J. 1998, 184: 548-552. 10.1038/sj.bdj.4809695.

    Article  PubMed  Google Scholar 

  89. 89.

    Palmer RM, Scott DA, Meekin TN, Poston RN, Odell EW, Wilson RF: Potential mechanisms of susceptibility to periodontitis in tobacco smokers. J Periodontal Res. 1999, 34: 363-369. 10.1111/j.1600-0765.1999.tb02267.x.

    Article  PubMed  Google Scholar 

  90. 90.

    Re G, Barbero P, Briccarello MP, Manzon W, Zoccola GC: Oral amoxicillin 1g b.i.d vs 1g t.i.d. in the treatment of oral periodontitis. Randomized and double-blind pilot trial. Minerva Stomatol. 1988, 37: 507-509.

    PubMed  Google Scholar 

  91. 91.

    Soder PO, Frithiof L, Wikner S, Wouters F, Engstrom PE, Rubin B, Nedlich U, Soder B: The effect of systemic metronidazole after non-surgical treatment in moderate and advanced periodontitis in young adults. J Periodontol. 1990, 61: 281-288. 10.1902/jop.1990.61.5.281.

    Article  PubMed  Google Scholar 

  92. 92.

    Sterry KA, Langeroudi M, Dolby AE: Metronidazole as an adjunct to periodontal therapy with sub-gingival curettage. Br Dent J. 1985, 158: 176-178. 10.1038/sj.bdj.4805568.

    Article  PubMed  Google Scholar 

  93. 93.

    Tinoco EM, Beldi MI, Campedelli F, Lana M, Loureiro CA, Bellini HT, Rams TE, Tinoco NM, Gjermo P, Preus HR: Clinical and microbiological effects of adjunctive antibiotics in treatment of localized juvenile periodontitis. A controlled clinical trial. J Periodontol. 1998, 69: 1355-1363. 10.1902/jop.1998.69.12.1355.

    Article  PubMed  Google Scholar 

  94. 94.

    Varela VM, Heller D, Silva-Senem MX, Torres MC, Colombo AP, Feres-Filho EJ: Systemic antimicrobials adjunctive to a repeated mechanical and antiseptic therapy for aggressive periodontitis: a 6-month randomized controlled trial. J Periodontol. 2011, 82: 1121-1130. 10.1902/jop.2011.100656.

    Article  PubMed  Google Scholar 

  95. 95.

    Vergani SA, Silva EB, Vinholis AH, Marcantonio RA: Systemic use of metronidazole in the treatment of chronic periodontitis: a pilot study using clinical, microbiological, and enzymatic evaluation. Braz Oral Res. 2004, 18: 121-127.

    Article  PubMed  Google Scholar 

  96. 96.

    Casarin RC, Peloso Ribeiro ED, Sallum EA, Nociti FHJ, Goncalves RB, Casati MZ: The combination of amoxicillin and metronidazole improves clinical and microbiologic results of one-stage, full-mouth, ultrasonic debridement in aggressive periodontitis treatment. J Periodontol. 2012, 83: 988-998. 10.1902/jop.2012.110513.

    Article  PubMed  Google Scholar 

  97. 97.

    Goodson JM, Haffajee AD, Socransky SS, Kent R, Teles R, Hasturk H, Bogren A, Van Dyke T, Wennstrom J, Lindhe J: Control of periodontal infections: a randomized controlled trial I. The primary outcome attachment gain and pocket depth reduction at treated sites. J Clin Periodontol. 2012, 39: 526-536. 10.1111/j.1600-051X.2012.01870.x.

    Article  PubMed  Google Scholar 

  98. 98.

    Mdala I, Haffajee AD, Socransky SS, de Blasio BF, Thoresen M, Olsen I, Goodson JM: Multilevel analysis of clinical parameters in chronic periodontitis after root planing/scaling, surgery, and systemic and local antibiotics: 2-year results. J Oral Microbiol. 2012, 4: ᅟ-doi:10.3402

    Article  Google Scholar 

  99. 99.

    Preus HR, Gunleiksrud TM, Sandvik L, Gjermo P, Baelum V: A randomized, double-masked clinical trial comparing four periodontitis treatment strategies: 1-year clinical results. J Periodontol. 2013, 84: 1075-1086. 10.1902/jop.2012.120400.

    Article  PubMed  Google Scholar 

Pre-publication history

  1. The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-6831/14/159/prepub

Download references

Acknowledgements

The authors would like to thank Mrs. Martin Gosteli and Mr. Philipp Stalder, librarians of the main library of the University of Zurich, who performed the electrical literature search.

Author information

Affiliations

Authors

Corresponding author

Correspondence to Philipp Sahrmann.

Additional information

Competing interests

The authors declare that they have no competing interests.

Authors’ contributions

PRS and PS conceived the study. MK and PS did the literature search. MK, UH and PS drafted the manuscript. UH did the statistical analysis and performed the meta-analysis. All authors participated in the writing process, read and approved the final text.

Authors’ original submitted files for images

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Kolakovic, M., Held, U., Schmidlin, P.R. et al. An estimate of pocket closure and avoided needs of surgery after scaling and root planing with systemic antibiotics: a systematic review. BMC Oral Health 14, 159 (2014). https://doi.org/10.1186/1472-6831-14-159

Download citation

Keywords

  • Periodontitis
  • Antibiotics
  • Treatment needs
  • Non-surgical therapy
  • Amoxicillin
  • Metronidazole
\