Periodontal Disease and Overall Health: A Clinician's Guide

CHAPTER 2 Overview of Periodontal Disease:CHAPTER 2 Causes, Pathogenesis, and Characteristics 19dazole can be used to treat acute necrotizingulcerative gingivitis (NUG), 52 and metronidazole/amoxicillincombination therapy canbe used to treat aggressive adolescent periodontitisassociated with A. actinomycetemcomitans.53 Systemic antibiotic therapy hasthe advantage of simple, easy administrationof drugs to multiple periodontal sites. However,patient compliance needs to be considered,inability to achieve adequate concentrationsat the site of infection, adverse drugreactions, and the develop ment of antibioticresistance can be issues. 54 Common antibiotictherapies for the treatment of periodontitisinclude metronidazole, clindamycin, doxycyclineor minocycline, ciprofloxacin,azithromycin, metronidazole/amoxicillin,and metronidazole/cipro floxacin. 55 For adultpatients with acute periodontal abscesses,amoxicillin is used as an adjunct to incisionand drainage. For patients with allergies tobeta-lactam drugs (e.g., amoxicillin), azith -romycin or clindamycin would be the choice.Researchers have shown that periodontaltreatment can benefit some systemic diseasesknown to be associated with periodontitis,such as diabetes and preterm delivery.Grossi and colleagues reported that diabeticpatients receiving scaling and root planingwith systemic doxycycline showed significantreductions in mean HbA1c. 56 Effectivetreatment of periodontal infection and reduc -tion of periodontal inflammation is associatedwith a reduction in levels of glycatedhemo globin. Clothier and colleagues alsoshowed that performing scaling and root planingin pregnant women with periodontitismay reduce preterm delivery. 57 However, ad -junc tive metronidazole therapy did not im -prove pregnancy outcomes. Two recent studieshave not shown improvements in adversepregnancy outcomes with scaling and rootplaning. 58 However, the level of perio dontaltreatment provided may have been veryinadequate. More studies are needed in thisfield to determine the effect of periodontaltreatment on the outcomes of adverse pregnancyand the extent of therapy that mayneed to be provided in order to have a significantimpact.Host-Modulation TherapyBacteria and the host are two essentialfactors to the development of periodontitis.Reduction of bacterial load is the con -ventional approach for the management ofperiodontal diseases. More recently, periodontaltreatment strategies have includedhost-modulation therapy as an adjunctivetreatment option. Host-modulation therapy istreating the host response to either reduce theexcess production of cytokines and destructiveenzymes so there is less damage to theperiodontal tissues, or to stimulate the regenerative process, allowing for the restorationof connective tissue attachment andbone formation to occur.Host modulation was first introduced todentistry by Williams 59 and Golub and colleagues.60 Williams stated: “There are compellingdata from studies in animals and humantrials indicating that pharmacologicagents that modulate the host responses believedto be involved in the pathogenesis ofperiodontal destruction may be efficacious inslowing the progression of periodontitis.” 59Golub and colleagues discussed “host modulationwith tetracyclines and their chemicallymodified analogues.” 60 A variety of differentdrug classes have been evaluated ashost-modulation agents, including the non -steroidal anti-inflammatory drugs, bisphosphonates,tetracyclines (Figure 4), 36 enamelmatrix proteins, growth factors, and bonemorphogenetic proteins.Systemically Administered AgentsSubantimicrobial-Dose DoxycyclineSubantimicrobial-dose doxycycline (SDD)is the only FDA-approved MMP inhibitorand systemic host-modulation therapy for the