As the result of observations of the responses of patients with advanced periodontal problems to azithromycin, I now use the following protocol. This protocol is being refined as new observations are made over time.
As a result of applying this protocol, it is very rare for me to see 'downhill' or extreme downhill' patients in my practice. I have observed a fundamental change in periodontal treatment needs (most advanced cases are now successfully managed with subgingival debridement only) and conversion of previously downhill cases to stable in the long term ie at least 2 years following a single course of azithromycin.
Advanced/ terminal chronic periodontitis
Aggressive periodontitis
Prescribe azithromycin at initial consultation, review patient after 4-6 weeks to formulate definitive periodontal treatment plan based on reduction of inflammation, periodontal pocketing, tooth mobility and patient's symptoms.
Patients report that gingival bleeding on brushing stops 1-2 weeks after taking azithromycin, reduced mobility. Clinically, periodontal improvement is generally noted after 4-6 weeks, pocket depth decreases as a result of resolution of inflammation and gingival recession. Pus exudate also stops during this time. Continuing beneficial effects are observed over long period of time (4-8-12-18 months) with gingival recontouring and further pocket depth reduction.
Concurrent periodontal treatment (4-6 weeks after first precribing azithromycin):
- Extract extremely hopeless teeth.
- Splint very loose teeth.
- Monthly subgingival debridement with power scaler and curettes, OHI, continue while tissues heal, pocket depths decrease and gingival tissues recontour.
- Monitor bone consolidation/ regeneration with PA/OPG 6-12 months.
- Periodontal surgery rarely necessary as pockets heal and gingival inflammation subsides.
Patients not responding to supportive periodontal therapy (SPT)
Prescribe azithromycin once patients have been identified as downhill after conventional periodontal therapy and on-going SPT.
Patients report that gingival bleeding on brushing stops 1-2 weeks after taking azithromycin. Periodontal pockets decrease and gingival inflammation is resolved. Downhill cases are converted to stable.
Continue SPT, I have noticed that intervals between SPT increase significantly (typically patients with ongoing inflammation and pocketing who used to attend 2-3 monthly now need to be seen 4-6 monthly and have achieved periodontal stability.
Moderate- severe gingival overgrowth related to calcium channel blocker medications
If drug substitution is not possible, consider prescribing a single course of azithromycin at the intitial consultation.
Regression of overgrowth observed at 6-12 weeks after azithromycin, this effect continues over many months. 6-12 weeks after prescribing azithromycin, simple subgingival debridement of the calculus deposits that were formerly subgingival is indicated. Periodontal surgery is not usually required as the gingival tissues are significantly remodeled presumably as a result of long-term activity/effect of azithromycin on gingival fibroblasts.
Peri-implantitis
Depending on severity, prescribe azithromycin at initial visit or after poor response to conventional treatment for peri-implantitis.
Protocol similar as for advanced chronic periodontitis. Of the limited number of cases I have treated, resolution of inflammation and reduction of pocket depth is observed in the same time frame as for resolution of periodontitis.
