This document reviews the use of systemic antibiotics as an adjunct to mechanical debridement in the treatment of periodontitis. It finds that while some studies show superior outcomes with adjunctive antibiotics, the role of antibiotics remains controversial. The key findings are:
1) Antibiotics alone without mechanical debridement are not effective treatments for periodontitis due to the biofilm structure protecting bacteria.
2) Adjunctive antibiotics may provide additional benefits over mechanical debridement alone, including greater reductions in pocket depth and clinical attachment gains.
3) The quality of mechanical debridement impacts outcomes, with more experienced clinicians achieving better results when combining antibiotics and debridement.
Decision making in systemic antibiotic therapy.pptxPrasanthThalur
This document discusses the use of systemic antibiotics as an adjunct to scaling and root planing in the treatment of periodontal disease. It provides information on types of antibiotic therapy, current understanding of the microbial etiology of periodontal disease, and guidelines for periodontal therapy. Systematic reviews have found additional benefits of adjunctive antibiotics including improved clinical attachment level gains and reduced risk of further attachment loss. However, questions remain about which specific antibiotics or combinations are most appropriate for different forms of periodontal infections. The document also discusses the rationale for using systemic antibiotics as well as their limitations when biofilms are present. It provides criteria for an ideal antibiotic for periodontal therapy and discusses various antibiotic options and their administration.
This document discusses local drug delivery in the treatment of periodontal disease. It provides background on the limitations of traditional mechanical debridement and systemic antibiotic therapy. It then describes various local drug delivery agents that have been used, including tetracycline fibers, doxycycline polymer, minocycline microspheres, chlorhexidine chips, and metronidazole gel. These local delivery methods aim to achieve higher drug concentrations at the site of infection for longer periods of time compared to systemic therapies. The document concludes that local drug delivery may improve outcomes, particularly at sites that do not respond well to conventional treatment.
This document discusses the use of antibiotics in endodontics. It covers the history of antibiotics, classifications of antibiotics based on chemical structure and mechanism of action, and the use of systemic and topical antibiotics in endodontic treatments. Specifically, it describes the indications for systemic antibiotics in treating conditions like acute apical abscesses and replantation of avulsed teeth. It also discusses various topical antibiotic formulations used in endodontics, including triple antibiotic paste (TAP), MTAD, and Tetraclean, providing details on their composition and antimicrobial efficacy.
1) Periodontal diseases like gingivitis and periodontitis are caused by bacterial plaque buildup above and below the gums. They affect many humans and animal species.
2) The document discusses the history and concepts of using systemic antibiotics to treat periodontal infections. It describes that periodontal infections can be endogenous from normal oral bacteria overgrowing, or exogenous from bacteria transmitted between individuals.
3) The types of periodontal infections include endogenous infections from normal oral bacteria, opportunistic infections in hosts with reduced immunity, superinfections involving atypical bacteria, and true infections from bacteria rarely found in healthy individuals like Porphyromonas gingivalis and Actinobacillus actin
This document discusses the use of antibiotics as an adjunct treatment for periodontal diseases. It provides guidelines for when antibiotic therapy is appropriate, including as an additional treatment for patients who continue experiencing periodontal breakdown despite conventional treatment. The document discusses factors to consider when selecting an antibiotic, including the specific pathogens involved, the patient's medical history, and antibiotic properties. Commonly used antibiotics for periodontal diseases are described, including tetracycline, metronidazole, penicillin, clindamycin, ciprofloxacin, and macrolides.
This document discusses various studies on the use of antibiotic prophylaxis in different dental procedures and conditions. It summarizes several randomized controlled trials that evaluated the effectiveness of short-term versus long-term antibiotic regimens for procedures like orthognathic surgery and mandible fracture treatment, and whether they reduce postoperative infection rates. It also reviews evidence that supports the use of preoperative antibiotic prophylaxis for third molar surgery and clean neck dissections to lower risks of infection.
Decision making in systemic antibiotic therapy.pptxPrasanthThalur
This document discusses the use of systemic antibiotics as an adjunct to scaling and root planing in the treatment of periodontal disease. It provides information on types of antibiotic therapy, current understanding of the microbial etiology of periodontal disease, and guidelines for periodontal therapy. Systematic reviews have found additional benefits of adjunctive antibiotics including improved clinical attachment level gains and reduced risk of further attachment loss. However, questions remain about which specific antibiotics or combinations are most appropriate for different forms of periodontal infections. The document also discusses the rationale for using systemic antibiotics as well as their limitations when biofilms are present. It provides criteria for an ideal antibiotic for periodontal therapy and discusses various antibiotic options and their administration.
This document discusses local drug delivery in the treatment of periodontal disease. It provides background on the limitations of traditional mechanical debridement and systemic antibiotic therapy. It then describes various local drug delivery agents that have been used, including tetracycline fibers, doxycycline polymer, minocycline microspheres, chlorhexidine chips, and metronidazole gel. These local delivery methods aim to achieve higher drug concentrations at the site of infection for longer periods of time compared to systemic therapies. The document concludes that local drug delivery may improve outcomes, particularly at sites that do not respond well to conventional treatment.
This document discusses the use of antibiotics in endodontics. It covers the history of antibiotics, classifications of antibiotics based on chemical structure and mechanism of action, and the use of systemic and topical antibiotics in endodontic treatments. Specifically, it describes the indications for systemic antibiotics in treating conditions like acute apical abscesses and replantation of avulsed teeth. It also discusses various topical antibiotic formulations used in endodontics, including triple antibiotic paste (TAP), MTAD, and Tetraclean, providing details on their composition and antimicrobial efficacy.
1) Periodontal diseases like gingivitis and periodontitis are caused by bacterial plaque buildup above and below the gums. They affect many humans and animal species.
2) The document discusses the history and concepts of using systemic antibiotics to treat periodontal infections. It describes that periodontal infections can be endogenous from normal oral bacteria overgrowing, or exogenous from bacteria transmitted between individuals.
3) The types of periodontal infections include endogenous infections from normal oral bacteria, opportunistic infections in hosts with reduced immunity, superinfections involving atypical bacteria, and true infections from bacteria rarely found in healthy individuals like Porphyromonas gingivalis and Actinobacillus actin
This document discusses the use of antibiotics as an adjunct treatment for periodontal diseases. It provides guidelines for when antibiotic therapy is appropriate, including as an additional treatment for patients who continue experiencing periodontal breakdown despite conventional treatment. The document discusses factors to consider when selecting an antibiotic, including the specific pathogens involved, the patient's medical history, and antibiotic properties. Commonly used antibiotics for periodontal diseases are described, including tetracycline, metronidazole, penicillin, clindamycin, ciprofloxacin, and macrolides.
This document discusses various studies on the use of antibiotic prophylaxis in different dental procedures and conditions. It summarizes several randomized controlled trials that evaluated the effectiveness of short-term versus long-term antibiotic regimens for procedures like orthognathic surgery and mandible fracture treatment, and whether they reduce postoperative infection rates. It also reviews evidence that supports the use of preoperative antibiotic prophylaxis for third molar surgery and clean neck dissections to lower risks of infection.
This document provides an overview of local drug delivery (LDD) agents for the treatment of periodontal disease. It discusses the drawbacks of systemic therapies and advantages of LDD systems in achieving higher drug concentrations directly in the periodontal pockets. Various antimicrobial agents delivered locally via fibers, chips, gels and other vehicles are summarized, including tetracycline, doxycycline, minocycline, chlorhexidine, metronidazole and their efficacy. The importance of adequate drug-microbial contact time and biodegradability of different systems is also highlighted. In conclusion, LDD provides an effective adjunct to mechanical debridement, especially for refractory cases and sites difficult to access.
This document discusses the use of systemic antibiotics as an adjunct to treatment for periodontal diseases. It provides guidelines for when antibiotic therapy may be justified, such as for refractory or aggressive periodontitis. Key factors that affect the selection of an antibiotic include the patient's medical history, microbial analysis of plaque samples, and characteristics of the antibiotic like its spectrum of activity and pharmacokinetic profile. Commonly used antibiotics for periodontal diseases described are tetracyclines, metronidazole, penicillin, clindamycin, ciprofloxacin, and macrolides.
Formulation and evaluations of biodegradable nanoparticles based implant for ...Balasaheb Waghmare
This document discusses the formulation and evaluation of biodegradable nanoparticles for antifungal drug delivery in prosthetic joint replacement surgery. The key points are:
1) Prosthetic joint infections are a major complication of joint replacement surgery and can be caused by fungi like Candida albicans. Existing antifungal treatments have limitations like need for long-term use and systemic toxicity.
2) The study aims to develop a biodegradable nanoparticle-based implant to deliver the antifungal drug fluconazole locally for a sustained period to treat fungal prosthetic joint infections.
3) The plan of work involves pre-formulation studies, formulation of fluconazole-loaded
This document provides an overview of antibiotics used in periodontics. It begins with an introduction to antibiotics and their historical background. It then covers classification of antimicrobial agents based on chemical structure, mechanism of action, organisms targeted, and spectrum of activity. Guidelines for antibiotic use in periodontal diseases are presented, along with the diseases where antibiotics can be used. Commonly used antibiotics like tetracycline, doxycycline, metronidazole, penicillin, and amoxicillin-clavulanate are described in detail. The document concludes with a reference to research on systemic antibiotic use in periodontics.
Short-term improvement of clinical parameters and microbial diversity in peri...M ALTAMIMI
Indocyanine green-based antimicrobial photodynamic therapy as an adjunct to scaling and root planing resulted in significantly greater reductions in periodontal pocket depth and clinical attachment loss compared to scaling and root planing alone. Microbiome analysis showed a reduction in key periodontal pathogens like Porphyromonas gingivalis and favorable shifts in the subgingival microbiome with the addition of photodynamic therapy. The combination treatment led to significantly greater short-term clinical improvements and microbial changes associated with periodontal healing.
The document discusses microbial shifts and their relationship to periodontitis. It begins by explaining how biofilms form and provide advantages to bacteria, including increased attachment, metabolic cooperation, antibiotic resistance, and avoidance of the immune system. Quorum sensing allows bacteria to communicate and maintain homeostasis. However, homeostasis can break down, leading to shifts in the microbial balance that predispose sites to disease. Specifically, the subgingival microflora shifts from mainly gram-positive to increased gram-negative anaerobic bacteria. Adjunctive treatments for periodontitis are discussed, including antibiotics, antiseptics, host modulation therapy, photodynamic therapy, and probiotic therapy. The efficacy of treatment is assessed both biologically by examining
A Study on Pattern of Using Prophylactic Antibiotics in Caesarean Sectioniosrphr_editor
The IOSR Journal of Pharmacy (IOSRPHR) is an open access online & offline peer reviewed international journal, which publishes innovative research papers, reviews, mini-reviews, short communications and notes dealing with Pharmaceutical Sciences( Pharmaceutical Technology, Pharmaceutics, Biopharmaceutics, Pharmacokinetics, Pharmaceutical/Medicinal Chemistry, Computational Chemistry and Molecular Drug Design, Pharmacognosy & Phytochemistry, Pharmacology, Pharmaceutical Analysis, Pharmacy Practice, Clinical and Hospital Pharmacy, Cell Biology, Genomics and Proteomics, Pharmacogenomics, Bioinformatics and Biotechnology of Pharmaceutical Interest........more details on Aim & Scope).
Full Mouth Disinfection Versus Scaling and Root Planing per Quadrant in Agg...DR. ZERAIBI N
This document summarizes a systematic review comparing the effectiveness of full-mouth disinfection (FMD) versus scaling and root planing by quadrant (SRP-Q) for treating aggressive periodontitis. The review included two studies that found:
1) FMD resulted in slightly greater reductions in probing depth and clinical attachment loss compared to SRP-Q in some cases, but differences were minor.
2) One study found a statistically significant difference in bleeding on probing favoring FMD, while the other found no significant differences between the treatments.
3) Due to limitations and heterogeneity between studies, the review could not draw clear conclusions about the comparative effectiveness of FMD versus SRP-Q for treating aggressive periodontitis
This document discusses antimicrobial agents used in periodontics. It begins by explaining that periodontitis is caused by bacteria and that while antibiotics can kill bacteria, they cannot remove calculus or bacterial residues like scaling and root planing can. Adjunctive local or systemic antimicrobial therapies are sometimes used in addition to mechanical debridement. Systemic antimicrobials may provide some additional benefits but also carry risks, so should only be used in certain situations. Local drug delivery directly into periodontal pockets is an alternative that avoids systemic effects but must maintain effective drug concentrations over time to be effective against the subgingival biofilm.
Systemic antimicrobial therapy in periodontal diseases (3).pptmalti19
This document discusses the use of chemotherapeutic agents, specifically antimicrobial agents, for the treatment of periodontal diseases. It provides background on antimicrobial agents including antibiotics, antiseptics, and disinfectants. It then focuses on the use of two common antimicrobial agents used as adjuncts to mechanical debridement for periodontal therapy - metronidazole and tetracyclines. For both agents, it discusses their mechanisms of action, efficacy evidence from studies on types of periodontal diseases, advantages, limitations and side effects.
The document discusses the emergence of antimicrobial resistance due to the introduction and use of antimicrobials in humans and animals. It states that while antimicrobial resistance genes have existed naturally for thousands of years, the widespread use of antimicrobials has applied strong selective pressure that has led to growing antimicrobial resistance among human and animal pathogens. It also describes some of the associations seen between antimicrobial use and the emergence of resistance in various settings and bacterial species.
IOSRPHR(www.iosrphr.org) IOSR Journal of Pharmacyiosrphr_editor
This document summarizes a study on enhancing the sensitivity of multidrug resistant E. coli isolated from urine samples to commonly used antibiotics. 15 E. coli strains were tested, and 11 were resistant to most antibiotics. Strain EC8 was selected for sensitivity enhancement testing using non-toxic concentrations of homodium bromide over time periods of 6, 12, 18, and 24 hours. EC8 showed increased sensitivity to gentamicin, nitrofurantoin, and streptomycin after treatment. Higher concentrations of 0.85 and 0.95 ug/ml homodium bromide produced the greatest sensitivity enhancements. The results suggest homodium bromide may be useful as an enhancer of bacterial permeability to increase the effectiveness of antibiotics.
IOSRPHR(www.iosrphr.org) IOSR Journal of Pharmacyiosrphr_editor
This document summarizes a study that tested the ability of homodium bromide (HmBr) to enhance the antibiotic sensitivity of a multidrug resistant Escherichia coli isolate. The isolate was resistant to 8 of 11 antibiotics tested. Treatment with non-toxic concentrations of HmBr for various time periods increased the isolate's sensitivity to gentamicin, nitrofurantoin, and streptomycin in a time and concentration dependent manner, with higher concentrations and shorter incubation times producing greater enhancements. This suggests HmBr may be useful as an antibiotic sensitivity enhancer by increasing bacterial permeability.
An tibiotic policy in medical care seminardeepak deshkar
This document outlines an antibiotic policy and discusses the importance of prudent antibiotic usage to reduce antibiotic resistance. It notes that nearly half of hospitalized patients receive antibiotics. While antibiotics have been life-saving, their overuse for trivial infections, commercial pressures, and poverty have encouraged resistance. Antibiotic resistance arises from genetic changes and spread of R plasmids between bacteria. Indiscriminate antibiotic use in animals and humans has led to the spread of resistant organisms. The policy aims to reduce resistance by engaging all prescribers, restricting certain antibiotics, and ensuring adherence through surveillance and education. The roles of microbiologists, pharmacists, and continuous staff training are emphasized.
This document summarizes key points from a presentation on anti-infective therapy in periodontics. It discusses the rationale for using anti-infective agents as an adjunct to scaling and root planing, as SRP alone does not sufficiently modify the subgingival biofilm. It also covers the ideal requirements of anti-infective agents, classifications of agents, principles of antibiotic dosage and duration, guidelines for use, and considerations for choice of agent. Both systemic and local anti-infective agents are discussed.
The document discusses local drug delivery systems for treating periodontal disease. It covers the historical perspective of using antimicrobials as adjuncts to mechanical therapy. Various drug delivery methods are described including fibers, films, gels, strips, and microparticles. Specific drugs discussed include tetracycline, doxycycline, minocycline, and chlorhexidine. Studies show that local drug delivery of these antimicrobials can provide higher concentrations in periodontal pockets and help reduce probing depths and disease progression when used as an adjunct to scaling and root planing.
This document summarizes a critique of a pneumonia prevention policy at The University of Texas Medical Branch. The policy aims to prevent nosocomial pneumonia through measures such as preventing person-to-person transmission, aspiration prevention, postoperative pneumonia prevention, and equipment sterilization. However, the evidence review found that the policy was missing key elements like a comprehensive oral care plan, requirements for continuous endotracheal cuff pressure maintenance, and fully implementing ventilator bundle practices. The critique makes recommendations to update the policy based on current evidence, such as including an in-depth oral care regimen, specifying ventilator bundle elements, and providing more education resources to reduce non-compliance.
A presentation with bite. Improving oral health in an ageing populationNutrition & Biosciences
Did you miss our session on “A presentation with bite. Improving oral health in an ageing population”?
Click on the SlideShare to learn more from Dr. Anders Henriksson's presentation.
زويل اكاديمي حل الحالات الدراسية رقم 2 د حاتم البيطار.pdf2.pdfد حاتم البيطار
زويل اكاديمي حل الحالات الدراسية رقم 2 د حاتم البيطار.pdfزويل اكاديمي حل الحالات الدراسية رقم 2 د حاتم البيطار.pdfزويل اكاديمي حل الحالات الدراسية رقم 2 د حاتم البيطار.pdfزويل اكاديمي حل الحالات الدراسية رقم 2 د حاتم البيطار.pdfزويل اكاديمي حل الحالات الدراسية رقم 2 د حاتم البيطار.pdfزويل اكاديمي حل الحالات الدراسية رقم 2 د حاتم البيطار.pdfزويل اكاديمي حل الحالات الدراسية رقم 2 د حاتم البيطار.pdfزويل اكاديمي حل الحالات الدراسية رقم 2 د حاتم البيطار.pdfزويل اكاديمي حل الحالات الدراسية رقم 2 د حاتم البيطار.pdfزويل اكاديمي حل الحالات الدراسية رقم 2 د حاتم البيطار.pdfزويل اكاديمي حل الحالات الدراسية رقم 2 د حاتم البيطار.pdfزويل اكاديمي حل الحالات الدراسية رقم 2 د حاتم البيطار.pdfزويل اكاديمي حل الحالات الدراسية رقم 2 د حاتم البيطار.pdfزويل اكاديمي حل الحالات الدراسية رقم 2 د حاتم البيطار.pdfزويل اكاديمي حل الحالات الدراسية رقم 2 د حاتم البيطار.pdfزويل اكاديمي حل الحالات الدراسية رقم 2 د حاتم البيطار.pdf
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This document provides an overview of local drug delivery (LDD) agents for the treatment of periodontal disease. It discusses the drawbacks of systemic therapies and advantages of LDD systems in achieving higher drug concentrations directly in the periodontal pockets. Various antimicrobial agents delivered locally via fibers, chips, gels and other vehicles are summarized, including tetracycline, doxycycline, minocycline, chlorhexidine, metronidazole and their efficacy. The importance of adequate drug-microbial contact time and biodegradability of different systems is also highlighted. In conclusion, LDD provides an effective adjunct to mechanical debridement, especially for refractory cases and sites difficult to access.
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Systemic antibiotics in periodontal therapyامراض اللثة د حاتم البيطار.pdf
1. Australian Dental Journal 2009; 54:(1 Suppl): S96–S101
doi: 10.1111/j.1834-7819.2009.01147.x
Systemic antibiotics in periodontal therapy
LJA Heitz-Mayfield*
*Centre for Rural and Remote Oral Health, The University of Western Australia.
ABSTRACT
Periodontitis is a biofilm infection with a mixed microbial aetiology. Periodontitis is generally treated by non-surgical
mechanical debridement and regular periodontal maintenance care. Periodontal surgery may be indicated for some patients
to improve access to the root surface for mechanical debridement. A range of systemic antibiotics for treatment of
periodontitis has been documented, with some studies showing superior clinical outcomes following adjunctive antibiotics
while others do not. This has resulted in controversy as to the role of systemic antibiotics in the treatment of periodontal
diseases. Recent systematic reviews have provided an evidence-based assessment of the possible benefits of adjunctive
antibiotics in periodontal therapy. This review aims to provide an update on clinical issues of when and how to prescribe
systemic antibiotics in periodontal therapy.
Keywords: Systemic antibiotics, periodontal disease, treatment, aggressive periodontitis, chronic periodontitis.
INTRODUCTION
This review aims to provide the clinician with an
update on the current literature regarding the use of
systemic antibiotics in periodontal therapy. While the
use of systemic antimicrobials for treatment of peri-
odontitis has been controversial, the recent publication
of two systematic reviews1,2
has provided an unbiased
evidence-based assessment of the possible benefits of
systemic antibiotics. This paper will discuss some
important clinical questions regarding when and how
to use systemic antibiotics for the treatment of peri-
odontal disease.
Understanding the principles of using antibiotics for
treating periodontitis: what is the significance of the
periodontal biofilm when prescribing systemic
antibiotics?
Periodontitis is an infection caused by bacteria residing
in biofilms at or below the gingival margin (Fig 1). It is,
therefore, not surprising that a wide range of systemic
antibiotics have been used as part of periodontal
treatment aimed at targeting potential pathogenic
bacterial species within the periodontal biofilm.
The complex structure of the periodontal biofilm,
consisting of multiple bacterial communities residing in
a glycocalyx matrix, has been well described by Marsh
et al.3
It has been demonstrated that once bacteria
attach to a tooth surface and reside within a mature
biofilm structure they have a reduced susceptibility to
antimicrobials compared to planktonic or free floating
bacteria.4
Hence mechanical debridement is considered
critical to disrupt the biofilm when using systemic
antibiotics to treat periodontitis. The rationale for use
of adjunctive systemic antimicrobials is to further
reduce the bacterial load enabling resolution of the
inflammation in the periodontal pocket.
Should antibiotics be used as a monotherapy in the
treatment of periodontitis?
The question as to whether antibiotics prescribed as a
monotherapy, with no mechanical debridement, are
efficacious in the treatment of periodontitis was
addressed in a systematic review by Haffajee et al.2
From the results of four studies evaluating metronida-
zole alone5,6
or metronidazole combined with amoxi-
cillin as monotherapy7,8
it was concluded that the
effect of the antibiotic alone was minimal and short
term. The majority of studies do not support the
concept of monotherapy with inferior results in terms
of probing depth reduction, clinical attachment level
gain and reduction in bleeding compared with scaling
and root planing.9–11
Furthermore, Topoll et al.12
reported development of multiple periodontal absces-
ses in patients with advanced periodontal disease
who had been prescribed systemic antibiotic therapy
without subgingival debridement. The patients had
received broad-spectrum oral antibiotics (penicillin and
S96 ª 2009 Australian Dental Association
2. tetracycline) one to three weeks prior to the develop-
ment of abscesses. It was concluded that in patients
with advanced periodontal disease, systemic antibiotic
therapy without subgingival debridement might change
the composition of the subgingival microbiota, result-
ing in multiple periodontal abscesses.
Two recent studies13,14
created a great deal of
discussion in the periodontal community when they
showed similar clinical results for scaling and root
planing as for antibiotics (amoxicillin plus metronida-
zole) prescribed as a monotherapy. Lopez and Gamonal14
provided only short term, four month, microbiological
and clinical results, and Lopez et al.13
compared
supragingival scaling and antibiotic with subgingival
scaling and root planing and placebo. The authors
suggested that this treatment approach could be used in
populations with no or limited access to dental care.
However, the results of these studies are not supported
by the rest of the literature and should be interpreted
with caution. Furthermore, the risks of side effects and
development of antimicrobial resistance need to be
considered. Thus, mechanical debridement ensuring
adequate disruption of the biofilm continues to be
regarded as the appropriate treatment approach when
prescribing systemic antibiotics.
Do adjunctive systemic antibiotics offer an advantage
over non-surgical mechanical therapy alone for the
treatment of chronic periodontitis?
It has been well documented that the majority of
patients diagnosed with chronic periodontitis can be
successfully treated following mechanical debridement,
adequate oral hygiene and regular maintenance
care.15,16
At the fourth European Workshop, a system-
atic review by Hererra et al. concluded that systemic
antibiotics used in conjunction with scaling and root
planing can offer an additional benefit over scaling and
root planing alone in terms of probing depth reduction
(0.4 mm, spiramycin) and clinical attachment level gain
(0.5 mm, combination of amoxicillin and metronida-
zole) in pockets of 6 mm or deeper.1
Similar findings
were reported in the systematic review by Haffajee
et al.2
Do adjunctive systemic antibiotics offer an advantage
over surgical mechanical therapy alone?
Periodontal surgery may be indicated where there is
inadequate access for effective mechanical debride-
ment. A systematic review by Haffajee et al. reported
an additional clinical benefit in attachment level gain
(weighted mean gain 0.6 mm) when systemic anti-
biotics were prescribed as an adjunct to surgical
mechanical debridement in deep pockets.2
In this
meta-analysis the authors pooled results of three
studies17–19
using different antibiotics (penicillin, tet-
racycline, amoxicillin plus clavulanate) comparing
periodontal surgery plus antibiotic versus periodontal
surgery plus placebo. However, the most recent review
of the literature by Hererra et al. concluded that there
was insufficient data as to whether adjunctive antibi-
otics were beneficial when combined with periodontal
surgery.20
Does operator experience influence the quality of
debridement?
If we recognize the importance of disruption of the
periodontal biofilm, the quality of debridement is likely
to have an influence on the treatment outcome. There
is indirect evidence that when antibiotics are prescribed
in conjunction with mechanical debridement the level
of experience of the operator enhances clinical improve-
ments. Periodontists taking three to four hours for
treatment (using local anaesthesia where required)
obtained significant clinical improvements following
adjunctive antibiotics (amoxicillin and metronidazole)
when compared with scaling and root planing without
antibiotics.21,22
In contrast, less experienced clinicians
did not find significant differences.23
Choice of systemic antibiotic – which antibiotic is the
best to use?
Therapeutic success of an antimicrobial depends on the
activity of the antimicrobial agent against the infecting
organisms. Periodontitis is a mixed microbial infection
making the choice of antibiotic regimen difficult.
Certain antibiotics target specific parts of the subgin-
gival biofilm. For example, metronidazole targets the
gram-negative strict anaerobes from the red and orange
Socransky complexes24
such as Fusobacterium nuclea-
tum, Tanerella forsythia, Porphyromonas gingivalis
Fig 1. Chronic periodontitis: deep probing depths, abundant
supra- and subgingival biofilm.
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3. and Treponema denticola, while members of the genera
Actinomyces, Streptococcus and Capnocytophaga are
minimally affected by metronidazole. Metronidazole
also has a limited effect on the species Aggregatibacter
actinomycetemcomitans, which is a facultative anaer-
obe rather than a strict anaerobe. Amoxicillin has a
broader spectrum lowering counts of gram negative
anaerobes as well as decreasing the counts and propor-
tions of Actinomyces species during and after antibiotic
therapy.25
Micro-organisms can be intrinsically resis-
tant to antimicrobials or can develop acquired resis-
tance by emergence of resistant strains of bacteria that
would otherwise be considered to be sensitive to the
antimicrobial.
The literature reports a wide range of antibiotics used
in conjunction with non-surgical and surgical mechan-
ical debridement for the treatment of both chronic and
aggressive periodontitis. The most commonly used
antibiotics include tetracyclines, penicillins (amoxicil-
lin), metronidazole, macrolides (spiramycin, erythro-
mycin, azithromycin), clindamycin and ciprofloxacin.
The most common combination antibiotic regimen
reported is metronidazole and amoxicillin combined.
Table 1 lists common antibiotic regimens documented
in the literature for the treatment of periodontitis. It is
apparent that the literature does not provide a clear
indication of the superiority of one antibiotic regimen
over another and the choice of antibiotic should be
made on an individual basis.
What is the ideal duration, dosage and timing of the
antibiotic?
The dosage and duration of the antibiotic prescribed
also varies widely among studies and there is no
consensus on the ideal regimen. In principle it is
important to prescribe an antibiotic in sufficient dose
for adequate duration.
Another important clinical question is when to start
the antibiotics in relation to the mechanical phase of
treatment. Indirect evidence suggests that antibiotic
intake should start on the day of debridement
completion and debridement should be completed
within a short period of time (< 1 week).20
How critical is patient compliance when using
adjunctive antibiotics?
The issue of patient compliance has been infrequently
addressed in publications evaluating the effects of
systemic antibiotics. Some studies have shown that as
little as 20 per cent of patients comply with antibiotic
regimens prescribed.26
One advantage of the antibiotic azithromycin may be
that due to its pharmacologic properties and long half
life, only one tablet (500 mg) per day during three
consecutive days is required as opposed to one tablet
three times a day for seven days with other antibiotic
regimens.27
Compliance in terms of oral hygiene and mainte-
nance care should also be addressed. It should be
recognized that in studies where beneficial results
following adjunctive antibiotics were reported, patients
had received maintenance care and had good plaque
control. If a patient was non-compliant with oral
hygiene measures and maintenance protocols, then a
favourable treatment outcome following adjunctive
antibiotics was unlikely. Prescription of antibiotics is
no substitute for adequate debridement, good oral
hygiene and regular maintenance care.
Are adjunctive systemic antibiotics useful for the
treatment of aggressive periodontitis?
Aggressive periodontitis is a form of periodontitis
where there is a rapid progression of disease in either
a localized or generalized pattern affecting otherwise
healthy individuals.28
Aggressive periodontitis is fre-
quently associated with the presence of high levels of
subgingival Aggregatibacter actinomycetemcomitans,
A.a (formerly Actinobacillus actinomycetemcomitans)
and⁄or Porphyromonas gingivalis, P.g. It has been
shown that adjunctive antibiotics may be required to
eradicate or suppress these pathogens, which have the
potential to invade the periodontal tissues. In the
systematic review by Hererra et al. it was concluded
that adjunctive systemic antibiotics should be consid-
ered in cases of aggressive periodontitis.1
A recent
randomized clinical trial found that the adjunctive use
Table 1. Examples of antibiotic regimens documented for treatment of periodontitis
Antibiotic Antibiotic regimen Periodontal disease as described by authors First author ⁄ year
tetracycline 250 mg, 4 · day, 14 days advanced chronic periodontitis Al Joburi, 198938
doxycycline 200 mg, 1 · day, 8 days generalized rapidly progressive periodontitis Sigusch, 200139
spiramycin 1.5 UI, 2 · day, 14 days advanced periodontal disease Bain, 199440
azithromycin 500 mg, 1 · day, 3 days aggressive periodontitis Haas, 200829
metronidazole 250 mg, 3 · day, 7 days periodontitis > 10% spirochetes Loesche, 198441
clindamycin 150 mg, 4 · day, 10 days refractory periodontitis Walker, 199342
amoxicillin and metronidazole 375 mg, 3 · day, 8 days
250 mg, 3 · day, 8 days
chronic periodontitis
presence of A.a, P.g
Flemmig, 199843
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4. of azithromycin has the potential to improve the
treatment outcome in young patients with aggressive
periodontitis compared to non-surgical debridement
alone.29
Due to the rapid progression of the disease it is
advisable to refer patients diagnosed with aggressive
periodontitis for specialist treatment.
Should antibiotics be used when regenerative
periodontal therapy is attempted?
Studies evaluating periodontal regenerative procedures
using either barrier membrane technique (guided tissue
regeneration) or enamel matrix proteins (Emdogain)
commonly use adjunctive systemic antibiotics. The
rationale for use of the antibiotics is to prevent post-
surgical infection, particularly if membrane exposure
occurs and to optimize the potential for regeneration.
There is, however, very limited evidence for the
additional benefit of systemic antibiotics for the regen-
erative outcome. Studies investigating the regenerative
outcomes with enamel matrix derivatives have found
no added benefit when antibiotics were prescribed.30,31
Periodontal abscess – should systemic antibiotics be
prescribed?
The periodontal abscess is a lesion with extensive
periodontal breakdown occurring during a short period
of time with localized accumulation of pus.32
This
condition may cause systemic involvement and the
lesion generally has a large bacterial mass with a high
prevalence of well-recognized periodontal pathogens.
The periodontal abscess may occur in untreated peri-
odontitis patients or in treated patients in maintenance
therapy. The role of systemic antibiotics in the treat-
ment of the periodontal abscess is controversial. Some
authors advocate use of systemic antibiotics in combi-
nation with mechanical debridement or drainage.33
Others recommend systemic antibiotics only if a clear
systemic involvement is present such as lymphadenop-
athy, fever or malaise or when the infection is not well
localized.34
Mechanical debridement and drainage
through the periodontal pocket without antibiotics is
usually effective in the management of the periodontal
abscess (Figs 2 and 3).
Necrotizing periodontal diseases – should systemic
antibiotics be prescribed?
Necrotizing gingivitis and necrotising periodontitis are
infections showing clinical signs of necrosis and ulcer-
ation of the gingival margin and interdental papilla.
They are associated with pain, spontaneous gingival
bleeding and halitosis. The predisposing factors associ-
ated with the onset and progression of necrotizing
periodontal diseases include immunodeficiency, mal-
nutrition, stress, smoking and poor oral hygiene.28
Treatment involves debridement, oral rinses, oral
hygiene and management of pain. When there are
systemic manifestations such as fever or malaise
metronidazole, targeting the gram negative anaerobes,
should be prescribed in conjunction with mechanical
debridement.
What are the common side effects following systemic
antibiotics?
Within the literature there is a general lack of reporting
on the presence or absence of adverse events following
the adjunctive use of systemic antibiotics. Most adverse
effects, which have been reported, are minor and
related to gastrointestinal problems such as diarrhoea
and nausea.
However, serious adverse events such as allergic and
anaphlyactic reaction and pseudomembranous colitis,
Fig 2. Periodontal abscess: 11 mm probing depth, suppuration
and bleeding.
Fig 3. Healing following mechanical debridement without the
use of adjunctive systemic antibiotics. Resolution of the deep probing
depth, mesiobuccal gingival recession.
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5. may occur and patients should be informed of the
potential for adverse events both minor and major
when prescribing systemic antibiotics. Anaphylactic
responses to penicillin occur approximately once every
10 000 courses administered, with 10 per cent of these
being fatal.35
The use of antibiotics should be carefully
considered choosing agents that maximize antimicro-
bial activity and minimize potential drug interactions
and adverse reactions. A thorough medical history
should be taken prior to antibiotic prescription.
An increase in microbial resistance following the
use of systemic antibiotics has been evaluated in
few studies. Feres et al.36
identified antibiotic-resistant
species in subgingival plaque and saliva samples from
chronic periodontitis patients treated by scaling and
root planing followed by orally administered amoxicil-
lin or metronidazole. There was an increase in the
percentage of resistant subgingival species following
antibiotic administration. However, levels returned
to baseline after a relatively short period of time
(90 days).36
In Spain, where systemic antibiotics are readily
available over the counter without prescription and
widely used in the general population, it has been
shown that there was an increase in the microbial
resistance patterns of oral bacteria to commonly
prescribed antibiotics compared to the Netherlands
where antibiotics use is more restricted.37
This under-
lines the importance of development of microbial
resistance to antibiotics and the importance of respon-
sible use to prevent the global spread of resistant strains
of bacteria.
CONCLUSIONS
Systemic antibiotics should not be prescribed as a
monotherapy for the treatment of periodontitis. Sys-
temic antibiotics are useful antimicrobial agents for the
management of periodontal diseases when used in
conjunction with adequate mechanical debridement for
disruption of the subgingival biofilm. There is no
consensus as to the ideal antibiotic, dose, duration
and timing of antibiotics. Adjunctive systemic anti-
biotics should be considered in cases of aggressive
periodontitis. While the literature shows an added
clinical benefit following adjunctive systemic antibiotics
for the treatment of chronic periodontitis in deep
pockets, the decision to prescribe antibiotics should be
made on an individual basis. The extent and severity of
the periodontal disease as well as plaque control and
patient compliance issues should be addressed.
The patients’ medical history with respect to drug
allergies and current medications must be considered.
Patients should be well informed as to the possible side
effects and drug interactions that may arise following
systemic antibiotics.
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Address for correspondence:
Professor Lisa JA Heitz-Mayfield
Centre for Rural and Remote Oral Health
The University of Western Australia
35 Stirling Highway
Crawley WA 6009
Email: heitz.mayfield@iinet.net.au
ª 2009 Australian Dental Association S101
Systemic antibiotics in periodontal therapy
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