Systemic antibiotics for periodontal disease; prescribe or not to prescribe?

Dhanushka Leuke Bandara

Department of Oral Medicine and Periodontology, Faculty of Dental Sciences, University of Peradeniya, Peradeniya, Sri Lanka. E-mail: dhanulb@dental.pdn.ac.lk

Submitted: 10-Dec-2020,

Accepted in Revised Form: 10-Feb-2021,

Published: 18-Jun-2021

DOI: 10.4103/sidj.sidj_52_20

Saint Int Dent J 2021;5:1-2.

Copyright: © 2021 The Saint's International Dental Journal

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Disclaimer:

This article was originally published by Wolters Kluwer Medknow Publications & Media Pvt Ltd and has now been officially transferred to Society of Dental Research & Education due to a change in publishing entity.
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It is no longer uncommon for a patient to use systemic antibiotics independently without an expert advice to overcome periodontal infections. Owing to the misconception of the same microbiological etiology seen in similar periodontal diseases, this self-use of antibiotics is encouraged in patients suffering from periodontal infections. Still, after knowing the current facts and pathologies of a patient with periodontal disease, the reality may differ. The large diversity and the complex interactions within the plaque biofilms challenge the therapeutic concepts that target only a chemical agent’s antimicrobial activity. Every medical practitioner worldwide is now concerned about antibiotics being used by humans. They also believe that the overuse of these systemic drugs contributes to the increasing number of antibacterial infections that are making antibacterial drugs resistant.

IS IT POSSIBLE TO DISRUPT THE PLAQUE BIOFILMS WITH SYSTEMIC ANTIBIOTICS?

Systemic antibiotics indeed can reach most of the oral surfaces and fluids, in addition to having the potential to reach the tissue invaded periodontal pathogens such as Aggregatibacter actinomycetemcomitans.[1] However, an established biofilm can best be removed by a mechanical disruption, which can be achieved by debriding the site through scaling and root surface instrumentation procedures.[2] Further, mechanical debridement has been shown to shift the oral microbiota from a disease profile to a health-related profile that has not proven to be achieved using antibiotics.[3]

ARE WE CLEAR ON THE ROLE OF SYSTEMIC ANTIBIOTICS IN THE MANAGEMENT OF PERIODONTAL DISEASE? There is no clear winning side for the debate!

Systemic antibiotics have been usually indicated as an adjunct to periodontal debridement in:[4]

  1. Necrotizing periodontal diseases

  2. Acute periodontal infections associated with risk of spread of infection

  3. Severe progressive periodontitis

  4. Immunocompromised patients, e.g. poor glycemic control or other immunocompromised conditions.

Although treatment of aggressive periodontitis indicated for adjunctive systemic antibiotics, the latest findings of less distinct differences in the subgingival microbiota or the host response mechanisms have weakened the basis for such indication. Moreover, systemic antibiotics have not shown any significant difference in outcome between aggressive and chronic periodontitis patients.[4]

Most of the currently available evidence that has evaluated systemic antibiotics benefits is based on Stages III and IV periodontitis with Grade B and C progression rates. It is also worth noting that the periodontal treatment protocols would vary according to severity, complexity, risk of disease progression, and patient-level risk factors. Moreover, different regimens and a wide range of systemic antibiotics have shown diverse effectiveness. Therefore, the general application of the available evidence may not apply to all the presentations. Furthermore, it may be possible that the statistically significant outcomes shown in studies may not directly reflect the clinical significance. The combination of amoxicillin and metronidazole (MET) has shown more significant pocket-depth reduction, a higher percentage of pocket closure, clinical attachment gain, and reduced sites with bleeding on probing. In contrast, MET and azithromycin have shown some improvement to a lesser extent. Despite the type of drug, more adverse effects also have been reported in these study groups.[4]

WHAT IS DENTISTS’ ROLE?

Antibiotics are widely administered by dentists that account for about 7%–11% of all common prescriptions. In addition, the recent restrictions on dental treatment following the COVID-19 pandemic showed that this pattern was dramatically enhanced,[5] which could quickly raise the risk of antibiotic resistance growth and other possibly harmful effects. Therefore, the decision to prescribe an antibiotic adjunctive to periodontal debridement should have arrived following careful evaluation of the condition, the risk assessment, and the patients’ general health. Moreover, choosing the correct drug regimen and proper instructions to the patient will ensure the judicious use of antibiotics to minimizing the adverse effects. Nevertheless, to achieve a beneficial clinical and microbiological treatment outcome, the prescription of systemic antibiotics can never substitute optimal plaque management regimens, non-surgical debridement, and individually tailored maintenance care.

REFERENCES

1. Kim YC, Ko Y, Hong SD, Kim KY, Lee YH, Chae C, et al. Presence of Porphyromonas gingivalis and plasma cell dominance in gingival tissues with periodontitis. Oral Dis 2010;16:375-81. [CrossRef] [Google Scholar] [PubMed]

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