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SANZ et al .
Background
and Arestin (six studies, WMD = 0.28; 95% CI [0.20; 0.36]; p < .001). No significant adjunctive long-term effect was evident. Statistically significantly improved CAL change for products used as an adjunct to subgingival debridement on short-term follow-up (6–9 months) was identified for Ligosan ( n = 3, WMD = 0.41, 95% CI [0.06; 0.75]; p = .020) and Arestin ( n = 4, WMD = 0.52; 95% CI [0.15; 0.88]; p = .019). Long-term data did not show significant improvement of CAL for any product. Data on BOP and pocket closure were insuf - ficient. No information on NNT was provided. Estimated effect size indicates an increased effect of 10%–30% in PPD reduction.
Available evidence While the results from the meta-analysis (Teughels et al., 2020) re - vealed a statistically significantly improved outcome for systemically administrated antibiotics as an adjunct to subgingival debridement, the effect was confined to a limited group of antibiotics. A significantly improved PPD reduction at the 6-month follow-up was observed for metronidazole (MET) and amoxicillin (AMOX) ( n = 8; WMD = 0.43, 95% CI [0.36; 0.51]). Analysis of 12-month data revealed a signifi - cant adjunctive effect for MET + AMOX ( n = 7; WMD = 0.54, 95% CI [0.33; 0.74]) and MET ( n = 2; WMD = 0.26, 95% CI [0.13; 0.38]). The adjunctive use of MET + AMOX and MET resulted in a statisti - cally significant additional percentage of pocket closure at 6 and 12 months. Statistically significantly greater CAL gain and BOP reduc - tion for MET + AMOX at 6 and 12 months. The adjunctive effect of MET + AMOX on PPD reduction and CAL gain was more pronounced in initially deep than moderately deep pockets. There are no relevant data on the long-term (>12 months) effect of using systemic antibiot - ics as an adjunct to subgingival debridement. NNT was not assessed.
Risk of bias High risk of bias and heterogeneity in the majority of studies.
Balance of benefit and harm No increase in adverse effects or differences in PROMs were ob - served. Harm versus benefit considerations on the use of antibiotics need to be considered. Economic considerations High economic costs and limited availability of products in European countries need to be considered. 6.7 | Intervention: Use of adjunctive systemically administered antibiotics to subgingival instrumentation R2.16 | Does adjunctive systemically administered antibiotics improve the clinical outcome of subgingival instrumentation? Evidence-based recommendation (2.16) A Due to concerns about patient's health and the impact of systemic antibiotic use to public health, its routine use as adjunct to subgingival debridement in patients with periodontitis is not recommended . B The adjunctive use of specific systemic antibiotics may be considered for specific patient categories (e.g. generalized periodontitis Stage III in young adults). Supporting literature Teughels et al. (2020) Quality of evidence RCTs ( n = 28) with a double-blind, placebo- controlled, parallel design. Risk of bias was low for 20 of the studies, while seven studies had a high risk. PPD reduction at 6 months; MET + AMOX: n = 8, 867 patients. PPD reduction at 12 months; MET + AMOX: n = 7, 764 patients, MET: n = 2, 259 patients. A Grade of recommendation Grade A—↓↓ B Grade of recommendation Grade 0—↔ A Strength of consensus Consensus (0% of the group abstained due to potential CoI) B Strength of consensus Consensus (0% of the group abstained due to potential CoI)
Risk of bias Low risk of bias and low heterogeneity among studies.
Consistency High consistency of results.
Clinical relevance and effect size Effect size estimation on PPD reduction as opposed to subgingival debridement alone indicates an increased effect of about 40%–50%. Balance of benefit and harm While the MET + AMOX combination had the most pronounced effects on the clinical outcomes among the different types of sys - temic antimicrobial therapy, the regimen was also associated with the highest frequency of side effects. Global concerns regarding the overuse of antibiotics and the development of antibiotic resistance must be considered. Benefit versus harm analysis includes consider - ations on the overall use of antibiotics for the individual patient and public health. Systemic antibiotic regimens have shown long lasting impact on the faecal microbiome, including an increase in genes as - sociated with antimicrobial resistance. Applicability Due to concerns to patient's health and the impact of systemic an - tibiotic use to public health, its routine use as adjunct to subgingi - val debridement in patients with periodontitis is not recommended. Based on the available evidence, however, its adjunctive use may be considered for special patient categories (e.g. generalized periodon - titis Stage III in young adults).
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