1. AZITHROMYCIN AS AN ADJUNCTIVE TREATMENT OF GENERALIZED SEVERE CHRONIC PERIODONTITIS: CLINICAL, MICROBIOLOGIC AND BIOCHEMICAL PARAMETERS Buket Han, Gulnur Emingil, Guven Ozdermir JP 2012

2. INTRODUCTION  Chronic periodontitis is an infectious disease characterized by occurrence of destruction of periodontal supporting tissues that occurs over an extended period of time.  It is caused by the activity of specific periodontal pathogens that initiate the disease process.  Host factors including infiltrating cell populations, cytokines & matrix metalloproteinases are associated with most periodontal tissue breakdown leading to clinical signs of the disease.

3. Azithromycin ( Macrolide) is a systemic antibiotic is mainly effective against Gram +ve organisms and is effective against certain Gram –ve organisms including H. influenzae & C. trachomatis. It is a bacteriostatic agent with a t ½ of over 50 hrs. It is used in periodontal therapy because of its favourable pharmacological properties and low incidence of adverse effects. Azithromycin produces potent inhibition of Aggregatibacter actinomycetemcomitans and Porphyromonas gingivalis.( Goldstein et al 1999) Azithromycin is concentrated in the neutrophils, macrophages and fibroblasts all of which play a role in pathogenesis of periodontal diseases ( Amsden 2001)

4. Triple role of azithromycin: 1) Supresses periopathogens. 2) Anti- inflammatory activity 3) Improves clinical treatment outcome of patients with chronic & aggressive periodontitis. (Smith et al 2002) The concentration of azithromycin in inflammed gingiva is higher than in healthy gingiva. ( Burrell & Walters 2008)

5. AIM This study examines the efficacy of azithromycin used in combination with non-surgical periodontal therapy on the clinical and microbiological parameters and GCF MMP-8 over a period of 6 months in patients with severe chronic generalized periodontitis.

6. MATERIALS & METHODS STUDY DESIGN :

7. INCLUSION CRITERIA:  ≥ 16 teeth present  > 30% sites with ≥ 5mm CAL  ≥ 2 sites with PPD ≥ 6 mm in each quadrant that had BOP EXCLUSION CRITERIA:  Severe medical disorders/ history of systemic illness.  Known hypersensitivity to macrolide.  Those who received antibiotics or undergone periodontal treatment in the past 6 months.  Pregnant females  Smokers ( > 10 cigarettes per day)

8. TREATMENT: Full mouth SRP was performed; per quadrant on 4 sequential visits. Post SRP Test group : SRP+ Azithromycin 500 mg [ 1 OD for 3 days] Control group: SRP+ Placebo Baseline sampling: 2 days after screening. GCF sampling : 2 weeks 1 month 3 months 6 months Microbiologic sampling: 2 weeks 1 month 6 months

9. Sites examined: PPD & CAL: 6 sites around each tooth was recorded for full mouth. GCF samples were taken from mesiobuccal aspects of single rooted teeth exhibiting PPD ≥ 6mm. MMP- 8 levels was measured in the GCF by immunofluorescence assay Subgingival plaque sampling was taken from two preselected single rooted teeth with PPD ≥ 6mm.

10. Quantitative real time PCR was performed with hydridization probes using species specific probes for 5 periodontopathic pathogens. Porphyromonas gingivalis Aggregatibacter actinomycetemcomitans Prevotella intermedia Tannerella forsythia and Fusobacterium nucleatum.

11. RESULTS Group/Parameter Baseline to 1 Month Baseline to 3 Months Baseline to 6Months Azithromycin group (n = 14) Mean PD (mm) 1.56 ± 0.4* 1.79 ± 0.4* 1.81 ± 0.5* Mean PD (4 to 6 mm) 2.18 ± 0.2* 2.23 ± 0.3 2.32 ± 0.4 Mean PD (‡7 mm) 4.34 ± 0.9* 4.46 ± 0.8* 4.88 ± 1.1* Mean CAL (mm) 1.47 ± 0.3* 1.58 ± 0.4* 1.55 ± 0.5* Mean CAL (4 to 6 mm) 0.34 ± 0.2* 0.43 ± 0.3* 0.34 ± 0.2* Mean CAL (‡7 mm) 1.99 ± 3.0* 1.25 ± 1.9* 2.25 ± 3.1* % of sites with BOP 51.36 ± 20.7* 53.43 ± 20.3* 54.08 ± 19.3* % pockets conver ting from 64.43 ± 23.5 65.92 ± 22.1 79.33 ± 24.7 ‡7 mm to <4 mm Placebo group (n = 14) Mean PD (mm) 1.44 ± 0.5* 1.54 ± 0.4* 1.66 ± 0.5* Mean PD (4 to 6 mm) 2.28 ± 0.3* 2.30 ± 0.3 2.46 ± 0.3 Mean PD (‡7 mm) 4.11 ± 0.5* 4.16 ± 0.4* 4.45 ± 0.5* Mean CAL (mm) 1.36 ± 0.5* 1.48 ± 0.6* 1.54 ± 0.5* Mean CAL (4 to 6 mm) 0.33 ± 0.2* 0.31 ± 0.2* 0.39 ± 0.4* Mean CAL (‡7 mm) 1.15 ± 2.3 0.49 ± 0.7 0.54 ± 0.5 % of sites with BOP 47.07 ± 16.8* 48.00 ± 8.5* 50.29 ± 17.2* % pockets conver ting from 67.0 ± 26.3 58.7 ± 26.1 57.56 ± 30.5 ‡7 mm to <4 mm

12. Mean Percentage of Sites With Different PD and CAL Categories at Baseline and at Follow-Up Visits in the Azithromycin and Placebo Groups Group/Parameter Baseline 1 Month 3 Months 6 Months Azithromycin group (n = 14) PD (‡7 mm) (%) 8.88 – 10.2 0.06 – 0.2* 0.0 – 0.0* 0.05 – 0.2* PD (4 to 6 mm) (%) 49.29 – 14.1 9.16 – 10.5* 8.41 – 10.0* 7.95 – 10.2* CAL (‡7 mm) (%) 33.56 – 13.5 7.40 – 6.6* 8.32 – 8.0* 7.00 – 7.8* CAL (4 to 6 mm) (%) 54.04 – 10.1 60.31 – 13.3 60.45 – 15.8 62.19 – 15.3 CAL (‡4 mm) (%) 87.59 – 9.4 67.71 – 17.3* 68.75 – 17.3* 69.19 – 18.5* Placebo group (n = 14) PD (‡7 mm) (%) 7.20 – 6.7 0.07 – 0.2* 0.13 – 0.4* 0.09 – 0.2* PD (4 to 6 mm) (%) 49.12 – 12.0 9,87 – 8.5* 10.97 – 8.9* 6.91 – 7.5* CAL (‡7 mm) (%) 32.64 – 17.4 6.05 – 5.2* 7.09 – 5.8* 4.71 – 6.8* CAL (4 to 6 mm) (%) 50.07 – 11.5 57.48 – 16.6 59.39 – 13.1 54.03 – 14.2 CAL (‡4 mm) (%) 82.74 – 12.8 63.52 – 19.9* 66.42 – 17.2* 58.79 – 16.8*

14. Total Bacteria at Baseline, Post-Treatment, 2 Weeks, 1 Month, and 6 Months in the Azithromycin and Placebo Groups Baseline Post-Treatment 2 Weeks 1 Month 6 Months Azithromycin group (n = 14) Aa% 21.4 14.3 7.1 0 0 n 1.48E+03 – 5.35E+03 1.49E+05 – 5.54E+05 3.63E+01 – 1.36E+02 0 0 Pg % 100 85.7 92.9 85.7 100 n 2.98E+03 – 4.74E+03 1.36E+04 – 2.85E+04 8.57E+01 – 8.63E+01* 8.49E+01 – 9.23 E+0 1.34E+03 – 4.67E+03* Pi % 71.4 35.7 21.4* 28.6 21.4* n 4.47E+03 – 8.45E+03 8.01E+02 – 2.20E+03* 3.37E+03 – 1.19E+04* 1.47 E+02 – 2.70E+02* 5.55E+02 – 1.77E+03* Fn % 100 92.9† 92.9 92.9† 92.9 n 3.76E+04 – 6.45E+04 2.87E+04 – 5.75E+04* 2.32E+04 – 4.54E+04* 1.46E+04 – 4.69E+04* 3.89E+04 – 8.97E+04 Tf % 92.9 78.6 85.7 78.6 78.6 n 3.41E+04 – 6.65E+04 3.44E+04 – 6.51E+04* 2.77E+03 – 8.41E+03* 1.45E+03 – 3.94 E+03* 1.63E+04 – 4.58E+04* Placebo group (n = 14) Aa % 7.1 14.3 21.4 7.1 7.1 n 1.49E+01 – 5.56E+01 2.63E+03 – 9.82E+03 3.07E+04 – 1.15E +05 1.22E+03 – 4.57E+03 3.26E+02 – 1.22E+03 Pg % 100 100 100 92.9 100 n 1.63E+04 – 3.83E+04 4.85E+03 – 1.21E+04 1.30E+03 – 4.31E+03* 2.63E+02 – 4.74E+02* 1.96E+04 – 5.76E+04* Pi % 64.3 42.9 21.4* 28.6 28.6 n 5.59E+03 – 7.93E+03 1.37E+04 – 2.80E+04* 6.84E+03 – 1.80E+04* 1.92E+03 – 6.58E+03* 3.33E+03 – 1.13E+04* Fn % 92.9 100 85.7 100 100 n 2.94E+04 – 3.27E+04 3.97E+04 – 7.30E+04 2.42E+04 – 3.70E+04 1.66E+04 – 2.35E+04 3.73E+04 – 5.95E+04 Tf % 92.9 78.6 64.3 85.7 85.7 n 1.16E+05 – 2.73E+05 1.56E+04 – 3.62E+04* 1.27E+04 – 4.46E+04* 5.95E+03 – 2.06E+04* 4.84E+04 –1.53E+05*g

15. DISCUSSION  In sites of pocket ≥ 7 mm there was a reduction of approximately 4.4 mm and pockets initially 4 to 6 mm there was a reduction of approximately 2.4mm in both groups.  Both the groups had almost same percentage of pockets converting from ≥7 mm to ≤ 4 mm.  Both the groups had almost similar MMP 8 levels during the course of treatment.  The decrease in MMP 8 level in both the groups after SRP suggests the effectiveness of non- surgical therapy in decreasing the bacterial load. Azithromycin does not have any additional effect on GCF MMP 8 levels.  Among the periodontal pathogens investigated all tend to reappear 6 months after treatment. F. nucleatum alone shows greater reduction than the control group.

16. RELATED STUDIES Effects of Full-Mouth Scaling and Root Planing in Conjunction With Systemically Administered Azithromycin Kazuhiro Gomi et al (JP 2007) A double-blind placebo-controlled trial of azithromycin as an adjunct to non-surgical treatment of periodontitis in adults: clinical results. S. R. Smith et al (JCP 2002) Azithromycin as an adjunct to scaling and root planing in the treatment ofPorphyromonas gingivalis- associated periodontitis: a pilot study Alfonso Oteo et al (JCP 2010) Clinical and microbiological effects of azithromycin in the treatment of generalized chronic periodontitis: a randomized placebo-controlled clinical trial Eduardo Sampaio et al (JCP 2011) Mascarenhas (2005) & Traven.S (2007) showed that Azithromycin + SRP was beneficial in smokers with Chronic periodontitis.

17. CONCLUSION  Although Azithromycin is a promising drug for treatment of various infections due to its easy dose regime and pharmacological actions, the data from the present studies suggests no added benefit in the treatment of chronic periodontitis.  The effect on Azithromycin on Fusobacterium nucleatum may be beneficial to some extent.  Teles et al suggested that rapid reduction in periopathogens and an increase in beneficial species ratio is needed to achieve major clinical benefits. This ratio is difficult to achieve using a bacteriostatic agent such as Azithromycin.