Mombelli vs. Shapira

The EFP website has posted the other day a debate between Professors Lior Shapira of the Jerusalem Hebrew University and Andrea Mombelli, Geneva. Is it time to rethink the use of antibiotics in the treatment of periodontitis? Well, it actually is. One cannot continue just emphasizing the undeniable (if short-term) effect of antibiotics reducing the need and extent of periodontal surgery when administered as an adjunct to non-surgical treatment (Mombelli) without having the much bigger picture (real global threats of antibiotic resistance development) in mind (Shapiro). I have written about recent respective clinical reports on (transient) effects of adjunct antibiotics numerous times on this blog, see, for example here, here and here. I never concealed my opinion. Biofilm infections are indeed different.

While Shapira rightly mentions,

So what are the long-term benefits of the adjunctive use of antibiotics? The benefit of anti-malignant medication is calculated by “benefit in survival”, which we can translate in periodontal medicine as “the survival of an affected tooth over and above standard treatment methods.”  However, such data is not available and I have my doubts that we will be able to find any differences between these treatments in the long term,

Mombelli is inclined to list an array of highly questioned use of antibiotics in medicine and even husbandry,

[W]hen you eat your next beef steak, you might like to consider the following. The European Medicines Agency reported that 8,421 tonnes of antibiotics were sold as veterinary antimicrobial agents, applicable mainly to food-producing animals, in 25 EU/EEA countries in 2011.

The 1,947 tonnes of penicillin fed to these animals in one year – principally as a growth-promoter rather than for treating infection! – corresponds to the total dose necessary to treat 247 million human cases of periodontitis (375 mg t.i.d. for seven days equals 7,875 g amoxicillin), which is about half the entire population of these 25 countries.

Well, that’s playing down the problem. When Shapira argues, following a nowadays frequently quoted paradigm, that “[in] the course of periodontal disease, a dysbiosis of the normal oral flora triggers an inflammatory response, which in turn results in periodontal tissue damage,” it is more reasonable to assume that frequently administered systemic broad-spectrum antibiotics may actually cause dysbiosis both in the intestines and the oral cavity rather than reinstate a “normal” flora.

Given the facts that mechanical disruption of the biofilm is still the most promising means for treating periodontitis, and bony lesions and furcation involvements are difficult to access, what is so bad of periodontal access surgery, being it minimally invasive or not? Adjunct systemic antibiotics won’t eradicate remaining biofilms after insufficient debridement. There might be cases when infection occurs, i.e. invasion of and direct tissue destruction by periodontal microorganisms. We all may have our own old cases of aggressive periodontitis in mind (and show them in our lectures) in which adjunctive antibiotics (first tetracyclines, and later amoxicillin and metronidazole) had been part of an incredible success story.

But hasn’t that been the main reason for a differentiation between the two main types of periodontitis, juvenile and chronic?

6 September 2016 @ 6:55 am.

Last modified September 6, 2016.

 

 

 

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One comment

  1. Thomas W. Nabors, DDS,FACD

    Relative to this argument, is the patient with a periodontal infection that increases risk for heart disease, heart attack and ischemic stroke. Microbial patterns are a necessity in order to truthfully determine this risk relative to periodontal and peri-implant infections. The advocate for the use of antibiotics or to not use antibiotics should consider the residual affect of leaving Aa and Pg after treatment. (As both increase risk for MI and IS). Thus, the use of microbial testing using DNA-PCR is exceedingly more important from a systemic viewpoint than from a periodontal one. When we advocate that microbial testing is “not needed” (as the main stream approach), we actually miss the main point of microbial testing. So, as a profession, we are missing the most important role of our profession. To protect the health of our patients: As well as the issue of microbial testing relative the use antibiotics or not. In my lab experience, after reviewing over 250,000 microbial tests both before and after Rx, microbial tests are an absolute necessity for the Total Health model. The assumption that SRP actually removes Aa and Pg in every case is untrue. People are different and their infections are also. Thus, we must personalize the infection as well as the treatment.

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