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Dr Raluca Cosgarea is an associate professor in the Department of Periodontology, Operative and Preventive Dentistry at the University of Bonn and the Department of Periodontology and Peri-implant Diseases at the University of Marburg in Germany. Her research focuses on periodontics, namely the optimisation of protocols for the adjunctive use of systemic antibiotics in periodontal therapy. Her continued support for periodontal research is evidenced in her work and has led her to win multiple awards. In this interview with Dental Tribune International, Dr Cosgarea talks about her recent research endeavours and explains why it should be a worldwide goal to develop clear guidelines for antibiotic use in dentistry.
Dr Cosgarea, you are the recipient of the European Federation of Periodontology-Jaccard Research Prize in Periodontology 2022. How does it feel to be publicly acknowledged for your work in periodontal research?
Receiving the EFP-Jaccard Research Prize in Periodontology at the EuroPerio10 congress in Copenhagen this June represents the ultimate recognition of the research activities that I have carried out during the last decade. This award is a huge achievement and honour and demonstrates that everything in life can be accomplished provided one really wants it, works hard over the years to achieve it, and most importantly, is given the opportunity. In my case, the opportunity was granted by the EFP. This award not only humbles me but also motivates my team and me to work hard in the future for the benefit of our patients and European periodontics.
Could you tell us a bit about the objective of your research? What exactly did you investigate?
In light of the continuous global increase in antimicrobial resistance and the major threat caused by the arrival of dangerous, resistant microbial strains that are associated with prolonged antibiotic regimes, it seems relevant to limit and optimise the antibiotic protocols in periodontal therapy.
The objective of our study was to evaluate the clinical effects after non-surgical periodontal therapy, that is subgingival instrumentation, and adjunctive use of antibiotics, specifically the combination of amoxicillin and metronidazole administered for either a short course of three days or the traditional protocol of seven days, in young adults with aggressive periodontitis (Stage III/IV Grade C periodontitis). We also evaluated the adverse events and the microbiological and immunological effects of antibiotic use six months after treatment.
Your study found that both three- and seven-day antibiotic regimes led to statistically significant improvements at three and six months after treatment, but no statistically significant differences between the two treatment groups. How do you explain these findings?
We have shown that the three-day antibiotic course adjunctive to non-surgical mechanical debridement provided non-inferior clinical results after six months compared with the seven-day protocol in patients with aggressive forms of periodontitis. This means that a shorter antibiotic course of amoxicillin and metronidazole may allow us to obtain clinical results that are not worse than those obtained with a longer antibiotic course three and six months after treatment. These results were also supported by the microbiological and immunological outcomes of this study, indicating that we may obtain sufficient disease resolution at six months with a shorter antibiotic course prescribed for three days (amoxicillin and metronidazole, each 500 mg, three times daily) in younger patients with a severe or rapidly progressing form of periodontitis.
“It seems relevant to limit and optimise the antibiotic protocols in periodontal therapy”
Antibiotic overprescribing and antimicrobial resistance continue to be a serious concern in dentistry. What is your view of antibiotic stewardship in dentistry, and how does your study help to promote the appropriate use of antibiotics in periodontics?
So far, antibiotic stewardship has been promoted to a much lesser degree in dentistry than it has been in general medicine. An improvement of antibiotic stewardship through the development of clear guidelines providing clear indications for antibiotic use in dentistry should be a worldwide goal. In the S3-level clinical practice guideline for Stage I to III periodontitis published by the EFP in 2020, antibiotic prescription is recommended only for specific patient categories, such as young adults with Stage III periodontitis.
The first clear step is to optimise antibiotic prescription in periodontal treatment. Further support should be provided for research and the development of treatment alternatives to antibiotics as well as for the prevention and treatment of oral dysbiosis.
Our study is just a starting point that needs further research to prove the impact of a shorter systemic antibiotic course on antimicrobial resistance. Nonetheless, our study may help to optimise antibiotic prescription and is in line with the FDI World Dental Federation’s antibiotic stewardship principles.
Besides the desired clinical, microbiological and immunological effects in patients on the shorter antibiotic regime, fewer adverse events occurred in these patients. Could you please elaborate on this finding?
The three-day antibiotic protocol was associated with a lower frequency of adverse events compared with the seven-day protocol in our subjects, thus proving a better benefit-to-harm ratio. The adverse events were part of an exploratory analysis of the study and were not the main outcome variable. Thus, this aspect needs to be explored further in studies with a larger number of patients.
In light of your study, would you say that there is an urgent need to improve antibiotic protocols in the treatment of severe periodontitis with rapid progression?
According to the Review on Antimicrobial Resistance, chaired by Jim O`Neill in 2016, there is already a death toll of 700,000 people per year owing to antimicrobial resistance. It is predicted that this rate will reach 10 million deaths globally by 2050. Thus, there is an urgent need to improve antibiotic protocols and restrict their use as much as possible. This applies to every field, not only to periodontics.
Are you planning to explore the topic further in future research?
I plan to continue working on the topic in my future research, and I am determined to support the EFP and the European antibiotic stewardship programmes in their efforts to optimise antibiotic prescription and limit future death toll rates related to antimicrobial resistance.