1) The document discusses the rationale for use of antibiotics after periodontal surgery. While some studies support their use to reduce pain and swelling and improve healing, other studies found no benefit when surgery was performed under strict aseptic conditions. 2) The prevalence of postoperative infections after periodontal surgery is low (<1-4.4%) even without antibiotics. Strict aseptic protocols during surgery are important to prevent infections. 3) More recent studies and reviews have found no clear benefit to routine use of antibiotics after surgery to prevent infection alone. They may be indicated if infection is already present or for medical reasons.

1. RATIONALE FOR USE OF ANTIBIOTICS
AFTER PERIODONTAL SURGERY
DR.VIDYA VISHNU
SENIOR LECTURER
MALABAR DENTAL COLLEGE AND RESEARCH CENTRE
1

2. INTRODUCTION
 Of the various factors that affect the outcome of
periodontal surgery, the most important aspect is
prevention of infection during and following
surgery.
2

3.  As postoperative infection can have a significant
effect on the surgical outcome, preventive
measures like strict aseptic protocol, anti-infective
measures like proper sterilization, disinfection,
barrier techniques, and other measures should be
taken.
3

4.  Although studies have shown a low rate of
postoperative infection when periodontal surgery
was done under strict aseptic conditions, some
studies supported the concept that healing was rapid
and discomfort was lesser when antibiotics were
used.
4

5.  Other studies did not support the routine use of
antibiotics after periodontal surgery and concluded
that antibiotics should be used only when there is a
medical indication or when the infection has
already set in.
5

6.  With increase in use of bone grafts, GTR
membranes and implants, the use of antibiotics have
further increased.
 This seems to be based totally on empiricism and a
self developed protocol rather than based on
evidence.
 Hence, it is necessary to evaluate the role of
antibiotics after routine periodontal surgery, when
done under strict aseptic conditions.
6

7. Prevention of infection following
dental surgical procedures
 There are numerous local surgical and dental
surgical procedures and medical conditions that are
routinely covered by systemic antibiotics in an
attempt to prevent postoperative infections. These
can be considered as follows:
 local wound infection that may not jeopardize the
procedure (e.g. removal of an impacted lower third
molar);
7

8.  local infection that may jeopardize the
procedure (e.g. installation of endosseous
implants);
 distant metastatic infection (e.g. infection of an
indwelling vascular stent); and
 fulminant sepsis (e.g. the severely immuno-
compromised patient).
8

9. Local surgical procedures
Antibiotic prophylaxis can generally be justified for
surgical procedures when it may safely and cost
effectively reduce the risk for:
 exposing a sterile body area to infection; or
 acquiring an infection likely to cause major
morbidity, including the implantation of
prostheses.
9

10.  Considering these criteria, there are few clear
indications to provide antibiotic coverage for
dental and oral surgical procedures in fit and
healthy individuals (Pallasch TJ, Slots J.1996).
10

11. PERIODONTAL SURGERY
 Periodontal surgery, irrespective of the procedure,
has a low risk of postoperative infection. An analysis
of 1,053 periodontal surgical procedures showed a
prevalence of 22 infections (2.09%).
 Patients who received systemic antibiotics as part of
the surgical procedure (administered both pre- and
postoperatively) developed eight infections in 281
procedures (2.85%).
POWELL et al 2005
11

12. POST-OP INFECTIONS
 Infection is defined as an invasion of the body
tissues by pathogenic organisms.
 Oral cavity, which harbours billions of
microorganisms as their natural habitat, is also
influenced by a multitude of external factors, leading
to its susceptibility for infection.
12

13.  Though in actual practice, only a minority of
surgical procedures performed in the oral cavity
result in any significant post-surgical infection,
they could result in needless complications,
discomfort to the patient, delay in healing, and
can influence the final outcome as well.
13

14.  Sources of infection during surgery in oral cavity
include:
• Instruments,
• Hand of surgeon & assistant,
• Air of the operatory, and
• Patient’s perioral skin, nostrils, & saliva.
14

15.  Infection rates following periodontal surgery when
no antibiotics were used have been reported to be
low, ranging from <1% (Pack PD, Haber J.1983) to
4.4% (Checchi L, 1992) for routine periodontal
surgery and 4.5% following implant surgery
(Gynther et al, 1998).
15

16.  A literature review on effects of antibiotics on
implants showed success rate of 92% when no
antibiotics were used, 96% when prophylactic
antibiotics were used and 97% when postoperative
antibiotics were used.
16

17.  Prevalence of postoperative infections after a
range of periodontal surgical procedures is low and
systemic antibiotics are of little value in reducing
the incidence of postoperative infection. (Powell
2005)
17

18. Powell et al
2005
18

19. RATIONALE/ ADVANTAGES OF
POST-OPERATIVE ANTIBIOTICS
19

20.  to reduce pain & swelling,
 to improve wound healing
 To control the subgingival microflora
 To improve treatment outcomes following
gingivectomy, osseous resective, regenerative,
and implant surgery
20

21. PREVENTION OF POST-OP
INFECTIONS
 strict aseptic protocol,
 proper sterilization & disinfection,
 barrier techniques
21

22. Surgical aseptic protocol and
infection control measures
 All the periodontal surgical procedures should be
carried out in a fumigated enclosed surgical room
with restricted entry and proper drainage and water
supply system in place.
22

23.  Anybody with any source of infection should not
be allowed to enter the room.
 All personnel assigned in the operating room
should practice standard presurgical procedures
which included autoclaved surgical gowns, head
caps, masks, and separate in-house footwear.
23

24.  Dental operatory tools, including dental chair,
should be cleaned daily with a disinfectant.
 Exposed areas should be covered with aluminum
foils.
 Disposable glasses and autoclaved disposable
suction tips must be used along with distilled water
as water source.
24

25.  High-volume evacuation suctions should be used
for decreasing the aerosol production.
 Spittoon and tumbler water lines must be flushed
for at least 5 min before and after the surgical
procedure.
 All instruments to be used should be precleaned,
segregated, and packed in autoclavable sealed
pouches which had chemical spore testing test
strips attached to them and then autoclaved
25

26.  Operator and assistant should perform a presurgical
scrub with a germicidal soap using vigorous friction
before the surgical procedure.
 Patient preparation was done with povidone iodine
presurgical facial scrub.
 Pre-procedural mouthrinse with 10 ml of 0.2%
chlorhexidine must be done.
26

27. STUDIES
Ariaudo, 1969 :-
 Conducted a study on 68 patients to study the
efficacy of antibiotics after periodontal surgery .
 Lincomycin 500mg was given 1 capsule four times
a day for 6 days, 2 days before and four days after
surgery.
 Compared with placebo in control group reduced
the incidence of malaise, edema, necrosis and pain.
27

28. David, Strahan 1972
 Postoperative administration of phenoxymethyl
penicillin reduces the pain experience following
periodontal surgery, and may prevent postoperative
complications.
 As pain is normally controlled by analgesics, it may
be that their use is indicated where post operative
pain occurs following surgery, leaving antibiotics to
be used in cases where post operative complications
occur.
28

29. Thomas Marco, Edwin V . Kluth 1972
 Concluded that there will be no obvious
advantage to administering Cleocin post-
operatively to periodontal surgery patients.
29

30. Kidd EA, Wade AB 1974
 17 patients with a split mouth design, given a
course of Phenoxymethyl penicillin 250mg q.d.s
for 5 days compared to placebo.
 Resulted in lesser infection and better healing
following routine periodontal flap operation.
30

31. Scopp et al 1977
 Study on 20 patients - Tetracycline
hydrochloride 250mg 6th hourly for
5 days was compared to placebo after
periodontal surgery.
 Did not show any adverse outcome in both the
groups.
31

32.  K. Pendrill and J. Reddy 1980
 This study investigated the efficacy of prophylactic
penicillin in 19 human subjects undergoing
periodontal surgery.
 Following initial therapy, flap surgery was
undertaken in at least two comparable quadrants in
each patient.
 Using a split mouth technique, patients were either
given phenoxymethyl penicillin or a placebo
following flap surgery for 5 days.
32

33.  Pain, infection, plaque levels, gingivitis and
crevicular fluid flow were measured during a 4
week period.
 There were no differences between the placebo or
penicillin sides in any of the parameters studied,
except that the pain experience was significantly
lower on the penicillin operated side.
33

34. Pack PD, Haber J 1983
 A large scale study done in 218 patients in which 927
surgical techniques performed including flap surgeries,
grafts, osseous surgeries, frenectomy, root amputation.
 Prophylactic antibiotics were given in 43 surgeries
and 884 were done without antibiotics (Penicillin or
Erythromycin 250mg orally 4 times daily for 7 days).
 Antibiotic group- 1/43 (2%)
 Without antibiotics- 8/884 (<1%)
 Incidence of clinical infection was very low in both the
groups; prophylactic antibiotic therapy was ineffective in
preventing postoperative infection.
34

35. Mahmood, Dolby 1987
 In a double-blind cross over study done to
compare the effect of Metronidazole with placebo
in patients treated with Modified Widman flap
procedure
 Results showed that Metronidazole did not exert a
significant greater beneficial effect than placebo.
35

36. Chechi , Trombelli, Nonato 1992
 A retrospective study of 498 surgical procedures
done on 231 patients.
 250mg Tetracycline hydrochloride given 4 times a
day or Minocycline 100mg twice daily for 7 days
for 53 procedures and for 445 procedures no
antimicrobials was given.
 No statistical significant difference between the
incidence of infection in both the groups.
36

37. Powell 2005
 A retrospective review of 395 patients who underwent
1053 surgical procedures which included osseous
resective surgery, flap curettage, distal wedge
procedure, gingivectomy, root resection, implant
surgery, sinus augmentation, ridge preservation and the
impact of various treatment variables examined
including the use of bone grafts, membranes,
chlorhexidine rinses, soft tissue grafts, systemic
antibiotics and dressings
37

38.  Of the 1,053 surgical procedures, there were a total of
22 infections - 2.09%.
 Patients who received antibiotics (pre- and/ or post-
surgically) developed eight infections in 281
procedures (2.85%); compared to 14 infections in 772
procedures (1.81%) where antibiotics were not used.
 Procedures in which chlorhexidine was used during
post-surgical care had a lower infection rate (17
infections in 900 procedures, 1.89%) compared to
procedures after which chlorhexidine was not used as
part of post-surgical care (five infections in 153
procedures, 3.27%).
38

39.  The use of a post-surgical dressing demonstrated a
slightly higher rate of infection (eight infections in
300 procedures, 2.67%) than non-use of a dressing
(14 infections in 753 procedures, 1.86%).
 Concluded that there was no benefit in using
antibiotics for the sole purpose of preventing post
surgical infection.
39

40. Herrera et al- Systematic review
2008
 Concluded that unless there is a medical
indication, there is no justification for using
prophylactic antibiotic in periodontal surgery.
Even in some reports, an indiscriminate and
prolonged use of antibiotics may result in a higher
rate of infection.
 In addition, the risks involved with the use of
systemic antibiotics (adverse events, etc.) must
always be considered against the limited benefits.
40

41. Oswal et al 2014- RCT
(1) To evaluate the need of antibiotics in periodontal
surgeries in reducing postsurgical infections and
explore if antibiotics have any key role in
reducing or eliminating inflammatory
complications.
(2) To establish the incidence of postoperative
infections in relation to type of surgery and
determine those factors, which may affect
infection rates.
41

42.  Patients undergoing periodontal surgery were divided
into three categories: Group A (prophylactic), Group B
(therapeutic), and Group C (no antibiotics).
 Patients reported less pain and postoperative
discomfort when prophylactic antibiotics were given.
But, no statistical significant differences between the
three groups.
42

43.  There was no postoperative infection reported in
all the 90 sites operated in this study.
 The prevalence of postoperative infections
following periodontal surgery is <1% and this low
risk does not justify the routine use of systemic
antimicrobials just to prevent infections.
 Use of prophylactic antibiotics may have role in
prevention of inflammatory complication, but
not infection.
43

44.  Mohan, et al. 2014
 Conducted a RCT to evaluate the role of
antibiotics to prevent postoperative complications
after routine periodontal surgery and also to
determine whether their administration improved
the surgical outcome.
45

45.  Forty-five systemically healthy patients with
moderate to severe chronic periodontitis
requiring flap surgery were enrolled in the study.
 They were randomly allocated to Amoxicillin,
Doxycycline, and control groups.
46

46.  Surgical procedures were carried out with
complete asepsis.
 Postoperative assessment of patient variables
like swelling, pain, temperature, infection,
ulceration, necrosis, and trismus was performed
at intervals of 24 h, 48 h, 1 week, and 3 months.
 Changes in clinical parameters such as gingival
index, plaque index, PPD, and CAL were also
recorded.
47

47.  There was no incidence of postoperative
infection in any of the patients.
 Though there was significant improvement in
the periodontal parameters in all the groups, no
statistically significant result was observed for
any group over the others.
48

48.  Results of this study showed that when periodontal
surgical procedures were performed following
strict asepsis, the incidence of clinical infection
was not significant among all the three groups, and
also that antibiotic administration did not influence
the outcome of surgery.
 Therefore, prophylactic antibiotics for patients who
are otherwise healthy administered following
routine periodontal surgery to prevent
postoperative infection are unnecessary and have
no demonstrable additional benefits.
49

49. ABs in conjunction with periodontal
surgery aiming for periodontal
regeneration
 Studies evaluating regenerative procedures with
barrier membranes show a wide variability and lack
of predictable results.
 Negative outcomes: membrane exposure,
subsequent membrane infection and contamination
of the healing wound (Murphy 1995, Nowzari et al.
1996) resulting in reduced regeneration.
50

50.  Because of this, most researches investigating
regenerative procedures have used adjunctive
systemic antibiotics as part of the surgical
protocol (Cortellini & Bowers 1995, Machtei &
Schallhorn 1995, Cortellini & Tonetti 2000,
Kornman & Robertson 2000, Sanz & Giovannoli
2000).
51

51.  Powell et al. (2005) : use of regenerative
membranes did not significantly increase infection
rates (3.00%) compared with the non-use of
membranes (1.88%).
52

52.  The rationale for using antibiotics in these
procedures is to try to
 increase the predictability of the results by
controlling the subgingival microflora in the early
healing phase,
 in order to reduce the risk of post-operative
infection and
 Thus, reduce the chance of bacterial
contamination of the exposed membranes.
53

53.  Some of the studies have shown an additional
benefit in the regenerative outcomes in the test
group, either with amoxicillin plus clavulanate
(Nowzari et al. 1995) or ornidazole (Mombelli et
al. 1996).
54

54.  Other reports indicate that the group with
adjunctive antibiotics showed significant
improvements in the evaluated clinical parameters,
but did not have any significant effect on osseous
healing in class II furcation defects (Vest et al.
1999).
 Demolon et al. (1993, 1994) found large differences
among individuals and lack of sufficient bone
formation to fill any of the furcation defects,
indicating a low predictability of the procedure.
55

55.  In addition, they observed, at the 1-year reentry
surgery, that bone filling was limited and not
consistent with the observed clinical improvements.
 They concluded that the use of antibiotic may have
helped to control initial inflammation (Demolon et
al. 1993), but it had no direct effects of clinical
significance on bone regeneration or soft tissue
attachment at 12 months (Demolon et al. 1994).
56

56.  Other authors question the added clinical benefit of
applying barrier membranes and systemic
antibiotics, because none of them were relevant
factors, and only smoking has a strong impact on
the therapeutical outcomes in intra-osseous defects
(Loos et al. 2002).
 Studies of guided tissue regeneration with and
without antibiotics have used different regimens :
57

57. Study design, patients and treatment features of selected
papers assessing systemic antimicrobials as adjuncts to
regenerative surgery
Herrera et al 2008 58

58. 59

59.  In most of the published studies evaluating the
efficacy of the application of enamel matrix
derivatives (EMD) in regenerative periodontal
surgery, a post-operative antibiotic regimen was
used.
 Very few studies have compared this surgical
approach with and without the systemic
administration of antibiotics.
60

60.  Sculean 2001: observed no differences between
treatments, indicating that the positive healing can
be in great part be attributed to the use of EMD.
 This shows that careful patient selection, a
meticulous surgical technique and close post-
operative plaque control are more important
factors for the outcome of the therapy than the
routine administration of antibiotics.
61

61.  It should be emphasized that the application of
EMD in periodontal regenerative surgery leads to
fewer post-surgical complications than for other
regenerative approaches, such as the use of barrier
membranes or graft materials and, consequently, the
possibility of a post-operative infection is lower
(Sculean et al. 2001).
62

62.  Y. Liu et al. 2017
 Investigated the systemic antibiotic usage in the
perioperative period of periodontal flaps and its
relevance to the infection after surgeries through
reviewing RCTs between 2005 and 2014 that reported
periodontal flaps in chronic periodontitis patients.
 The rate of the systemic antibiotic use, the infection
rate after surgeries and the number needed to treat
(NNT) to prevent one infected case were calculated.
The impact of antibiotic use and materials used in
surgeries on the infection was evaluated.
63

63.  Eighty-three trials were included.
 In general, 73.7% of patients and 75.4% of
surgeries used systemic antibiotics in the
perioperative period of the periodontal flaps.
 Most surgeons from both developing and
developed countries chose to use antibiotics.
64

64.  The rate of antibiotic use was lower in developed
countries compared with developing countries,
whether a patient or a flap was used as the
statistical unit (p<.001).
 Infection occurred in only five flaps where EMD
or EMD+bone grafts were used in intrabony
defects.
 Only 0.170% of the surgeries got infected in total.
65

65.  When all kinds of surgeries were included for
analysis, the infection rate was 0.073% for the
surgeries using antibiotics, which was lower than
the infection rate 0.693% for the surgeries not
using antibiotics (p<.05).
 The infection rate was very low in general. NNT
was 203 when all the surgeries were included for
analysis.
 Therefore, the difference of the infection rates
between using antibiotics and not, might lack
clinical significance.
66

66. DENTAL IMPLANTS
68

67.  Abu-Ta’a et al. 2008
 RCT compared the usefulness of pre- and
postoperative antibiotics while strict asepsis was
followed during periodontal implant surgery
 Two groups of 43 patients each with fully or
partially Antibiotics group (GrAB1): 23 men,
received oral amoxicillin 1 g, 1 h pre-operatively
and 2 g for 2 days post-operatively.
 Non-antibiotics group (GrAB): 20 men, received
no antibiotics.
69

68.  There were no significant differences between
both groups, neither for the clinical parameters nor
for the microbiota. Staphylococcus aureus was
detected in the nares of one patient only.
 The patients’ subjective perception of post-
operative discomfort was significantly smaller in
the group receiving antibiotics.
 Three patients lost one or two implants.
70

69.  Thus the study concluded that Antibiotics do not
provide significant advantages concerning
postoperative infections in case of proper
asepsis.
 It also does not reduce peri-oral microbial
contamination.
 It does on the other hand reduce post-operative
discomfort.
71

70. Ahmad et al 2012 :
 Implants performed with the use of antibiotics had
a success rate of 96.5% while surgeries performed
without antibiotics had a slightly lower success rate
of 92%. When pre and post-op antibiotics were
compared, success rates of 96% and 97% were
found respectively.
 The overall success rate of implants when
antibiotics were used and when they were not used:
no significant difference .
72

71. Post-op Success Rates
73

72. DISADVANTAGES OF POST-
OPERATIVE ANTIBIOTICS
74

73.  Toxicity
 Hypersensitivity
 Drug resistance
 Superinfection
 Nutritional deficiencies
 Masking of an infection
75

74.  development of gastrointestinal tract problem,
 drug interactions with concomitant medications
 increased cost of treatment
76

75. AMOXYCILLIN
 diarrhoea, rash, vomiting and nausea
 rare but life-threatening reactions like toxic
epidermal necrolysis
 Stevens–Johnson syndrome
77

76. CONCLUSION
 Antimicrobials are powerful agents when used in
well-focused ways.
 Various retrospective and prospective controlled
studies have reported no benefit seen from the use
of antibiotics even in low to moderate risk dental
implant patients.
78

77.  Hence, it is important that the dental profession
diligently consider its responsibility to curb the use
of unnecessary antibiotics and keep antibiotic
efficacy high for when they are truly necessary.
79

78.  They should be held in reserve for treatment of
certain forms of advanced periodontal diseases
(refractory, aggressive), in systemically
compromised individuals with a reduced host
response and in treatment of postsurgical infections.
 The other reasons can be when surgery is performed
in an infected site, when the procedure is extensive
taking >2 h or when large foreign materials are
implanted.
80

79.  Various other factors are more important in
protecting the patient from postoperative infections
include aseptic protocol, skill and experience of
surgeon, tissue manipulation and surgical
technique, duration of surgery and control of
systemic and local risk factors with increased
susceptibility to infections.
 Hence, use of antibiotics should not be generalized
or used blindly just to be extra cautious in
preventing infection.
81

80. REFERENCES..
 Powell CA, Mealy BL, Deas DE, McDonnel HT, Moritz AJ.
Post surgical infections: Prevalence associated with various
periodontal surgical procedures. J Periodontol
2005;76:329-333.
 Ariaudo AA. The efficacy of antibiotics in periodontal
surgery: A controlled study with Lincomycin and Placebo in
68 patients. J Periodontol 1969;40:150-4.
 Kidd EA, Wade AB. Penicillin control of swelling and pain
after periodontal osseous surgery. J Clin Periodontol
1974;1:52-7.
 Scopp IW, Fletcher PD, Wynman BS, Epstein SR, Fine A.
Tetracycline: Double blind clinical study to evaluate the
effectiveness in periodontal surgery. J Periodontol
1977;48:484-6. 82

81.  Appleman MD, Sutter VL, Sims TN. Value of antibiotic
prophylaxis in periodontal surgery. J Periodontol
1982;53:319-24.
 Pack PD, Haber J. The incidence of clinical infection after
periodontal surgery. J Periodontol 1983;54:441-3.
 Chechi L, Trombelli L, Nonato M. Postoperative infections
and tetracycline prophylaxis in periodontal surgery: A
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 Effects of Antibiotic Treatment on Clinical Conditions with
Guided Tissue Regeneration: One-Year Results. Isabelle A.
Demolon, G. Rutger Persson, William F. Ammons, and
Robert H. Johnson. J Periodontol 1994; 65:713-717.
 Ahmad N, Saad N. Effects of antibiotics on dental implants:
A review. J Clin Med Res 2012;4:1-6.
83

82.  Oswal S, Ravindra S, Sinha A, Manjunath S. Antibiotics in
periodontal surgeries: A prospective randomised cross over
clinical trial. J Indian Soc Periodontol 2014;18:570-4.
 Mohan RR, Doraswamy DC, Hussain AM, Gundannavar G,
Subbaiah SK, Jayaprakash D. Evaluation of the role of
antibiotics in preventing postoperative complication after
routine periodontal surgery: A comparative clinical study. J
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