Radiographic osseous regeneration after initial therapy with systemic doxycycline

Military Medicine, Oct 2000 by Fowler, Edward B

Early-onset periodontal diseases are often diagnosed in the military as a result of the requirements for annual dental examinations and the youthful population served. A young soldier diagnosed with rapidly progressive periodontitis completed initial therapy of root planing with the systemic antibiotic doxycycline but was poorly compliant with additional treatment. During a subsequent mandatory dental examination, new radiographs demonstrated a significant improvement in the quantity and quality of alveolar bone, illustrating the regeneration potential of the young patient with earlyonset periodontal disease.

Introduction

Page et al.1 describe rapidly progressive periodontitis (RPP) as a distinct form of periodontal disease affecting the patient from puberty to 35 years old. RPP is characterized by phases of acute disease and quiescence. The disease is generalized but without any distinct pattern of distribution. Usually, spontaneous cessation and resolution of gingival inflammation follow the active phase. It is reported that approximately 83% of individuals with RPP have a functional defect in their polymorphonuclear neutrophils or monocytes. Additionally, some patients with RPP may have previously been diagnosed with juvenile periodontitis. As with juvenile periodontitis, RPP patients have variable quantities of local factors (bacterial plaque and calculus). Page and coworkers1 report that some patients with rapidly progressive periodontitis respond remarkably well to scaling and root planing (either open or closed) with the concurrent use of systemic antibiotics.

Doxycycline is a semisynthetic tetracycline. it is effective against many Gram-positive and Gram-negative microorganisms, along with rickettsiae and amoebae among the susceptible parasites. It is a bacteriostatic agent that at optimal concentrations inhibits bacterial growth. Doxycycline's primary effect is to inhibit protein synthesis. It reversibly binds to the 30S subunit of the ribosome, inhibiting the attachment of aminoacyl-tRNA. Thus, doxycycline blocks the addition of amino acids to the growing peptide chain during translation.2-5

Doxycycline has several benefits for use over traditional tetracyclines. Doxycycline is taken either once or twice each day compared with the four-times-daily regimen of tetracycline, thereby increasing patient compliance.6 In contrast to tetracycline, doxycycline has minimal to no interactions with calcium or dairy products. Additionally, doxycycline is reported to have fewer gastrointestinal side effects. Doxycycline does not induce photosensitivity, as tetracycline might. Doxycycline is excreted in the liver rather than the kidneys. As a result, doxycycline can be safely prescribed to patients with renal disease.2-5,7

The dental literature contains many studies comparing different therapeutic modalities in early-onset periodontal diseases (EOP). Most studies with localized juvenile periodontal disease (LJP) recommend the use of systemic tetracycline. Seymour and Heasman noted that concurrent use of 1 g of tetracycline per day for 14 days with either surgical or nonsurgical treatment enhanced the reduction of inflammation, the gain in clinical attachment levels, and the refill of angular bony defects in LJP.8

Christersson et al. treated seven WP patients with surgical and nonsurgical therapy and determined that neither was consistent in treating this disease, supporting the concept that antibiotic administration is needed to prevent reinfection with Actinobacillus actinomycetemcomitans (Aa), the bacteria most often implicated in LJP.9 Slots and Rosling compared different treatment modalities for LJP and determined that systemic tetracycline was required to be continued for 3 weeks when treating this disease entity.10

After successful treatment of a 12-year-old patient with IP using nonsurgical therapy and systemic tetracycline, Mattout and coworkers reported that as long as the inflammation of the periodontal pocket was eliminated, a successful result could be obtained. They felt that the healing potential of WP patients was superior to that of adult-onset periodontitis patients.11

Novak et al. treated four young patients with LIP with supragingival plaque control and systemic antibiotics.12 Patients took 250 mg of tetracycline four times daily for 3 to 6 weeks. Dental prophylaxis was provided every 2 weeks for 3 months, then once every 3 months. At a 3-month reevaluation, radiographs showed an increase in height and area of coronal bone by 38% (an average of 1.7 mm). When these same patients were reevaluated, the improvements noted at 3 months were stable for up to 4 years. The authors reported that based on radiographic examination, angular bony defects were repaired by an average of 72%.13

Gunsolley and coworkers followed 40 WP and 48 generalized EOP patients for an average of 3 to 4 years. They determined that the WP patients who received periodontal therapy gained attachment, whereas those who did not receive periodontal care lost attachment. However, the generalized EOP patients were found to have lost attachment regardless of whether or not they received periodontal treatment. On average, the generalized EOP patients lost one tooth after just 4 years. These researchers felt that LJP was a stable disease, whereas generalized EOP patients continued to lose both periodontal attachment and teeth. 14