Use of adjuncts in periodontal treatment for patients with diabetes

Background + Aims

• Diabetes mellitus (DM) is a significant risk factor for periodontitis, particularly in individuals with poor glycaemic control.
• Patients with diabetes exhibit higher prevalence and severity of periodontitis due to mechanisms such as increased infection risk and impaired wound healing.
• Evidence suggests a bidirectional relationship between periodontitis and DM, with periodontitis potentially exacerbating diabetic complications and dysregulating glycaemic control.
• While scaling and root planing (SRP) is a foundational periodontal therapy, it may be insufficient in diabetic patients for achieving optimal periodontal health. Adjuvant therapies, such as systemic antimicrobials, are being explored to enhance SRP outcomes by targeting pathogenic microbes and supporting a host-compatible microbiota.
• This systematic review aims to evaluate the efficacy of systemic antibiotics as adjuncts to SRP in improving periodontal outcomes in patients with diabetes.

Materials + Methods

• The study focused on the effects of systemic antibiotics as adjuncts to non-surgical periodontal therapy (NSPT) in patients with periodontitis and diabetes.
• The PICOS framework included:
  • Population – Individuals with periodontitis and diabetes
  • Intervention – systemic antibiotics adjunctive to SRP
  • Comparison – SRP alone or with placebo
  • Outcomes –
    • Primary: changes in clinical attachment level (CAL) and probing pocket depth (PPD)
    • Secondary: bleeding on probing (BOP), gingival inflammation (GI), and plaque index (PI)
  • Studies – Randomised controlled trials (RCTs) with ≥3-months follow-up.
• 2 reviewers independently screened studies and extracted data, resolving disagreements through discussion or a third reviewer.
• Extracted data included demographic characteristics, treatment protocols, clinical outcomes, and adverse events.
• Risk of bias was assessed using Cochrane-specific criteria across 10 domains, with discrepancies resolved by consensus.
• Meta-analyses were conducted using a random effects model to calculate weighted mean differences for primary and secondary outcomes. Heterogeneity was assessed via the I² statistic, and subgroup analyses were performed based on antibiotic type, follow-up duration, and SRP approach.
• Statistical significance was set at p ≤ 0.05.

Results

• The systematic review analysed 13 RCTs from a comprehensive search of 2,534 articles.
• Follow-up periods ranged from 3- to 12-months.
• Most studies focused on type 2 diabetes mellitus (T2DM), while a few included type 1 (T1DM) or both.
• Periodontal disease was generally classified as moderate to severe chronic periodontitis, with criteria varying among studies.
• The findings demonstrated:
  • Significant improvements in PPD reduction and CAL gain in groups treated with adjunctive antibiotics compared to SRP alone.
  • For PPD, the weighted mean difference (WMD) at the end of the trial was 0.15 mm (p = 0.001), favouring antibiotics.
  • CAL also showed improvements (WMD = 0.14 mm), though the result was not statistically significant (p = 0.11).
  • Subgroup analyses highlighted better PD outcomes with doxycycline, 3–6 months follow-up, and full-mouth treatment protocols.
  • 9- to 12–month follow-ups and conventional quadrant-based SRP contributed to moderate heterogeneity (I² = 56% for CAL; I² = 58% for PD).
  • BOP, GI and PI demonstrated no significant differences between test and control groups.
  • Minor adverse effects, such as gastrointestinal discomfort and dizziness, were reported in a few studies, but the majority did not report adverse events or noted their absence.
  • Heterogeneity was low for baseline measures (I² = 0%) but moderate to considerable for end-of-trial outcomes.
  • Sensitivity analyses, excluding one study, reduced heterogeneity for PD and CAL outcomes, suggesting robustness of the findings.

Limitations