Antibiotic prescribing
Periodontitis
In specialist periodontal practice, systemic antibiotics are often used as an adjunct to debridement to reduce pocket depth and increase attachement.
Worldwide, many different antibiotics are used for this, often with no regard to either antibiotic stewardship or efficacy.
Research has shown that systemic antibiotics are only effective for Stage III, IV periodontitis Grade C in patients aged less than 45 years, where disease is progressing despite excellent debridement, OH, and motivation. This classification means severe and rapidly progressing periodontal disease, with extensive destruction of underlying bone.
Primary Antimicrobial Choices for Stage III, IV periodontitis Grade C
Consistent evidence supports the use of amoxicillin and metronidazole combination as primary systemic antimicrobials in the treatment of this severe and rapidly progressing periodontitis. The effectiveness of this combination has been demonstrated in a systematic review and meta-analysis of randomized control trials (RCTs), with significant, albeit small, improvements in clinical attachment levels and periodontal pocket depth reductions compared to root surface debridement alone.
The effectiveness of both a 3-day and 7-day regime of these antimicrobials has been demonstrated in placebo-controlled RCTs. Shorter (3 day) duration regimes are favoured due to the potential for reducing side effects and selective resistance.
Secondary Antimicrobial Choices
In instances where amoxicillin and metronidazole combination is not suitable (e.g. allergy, intolerance), the secondary choice is azithromycin. This macrolide antibiotic has been shown to provide adjunctive benefits, particularly in cases with deeper periodontal sites.
Other Antimicrobial Considerations
Doxycycline remains another viable option. It has a higher availability in the gingival crevice and is significantly active against Aggregatibacter actinomycetemcomitan. However, doxycycline has shown mixed but generally inferior results compared to the primary choices.
Beyond doxycycline, several other antibiotics have been deployed worldwide in the management of rapidly progressing periodontitis. These include tetracycline, minocycline, clindamycin, and co-amoxiclav. Each of these antimicrobials has unique properties that can be beneficial in treating specific periodontal conditions, yet their use comes with distinct challenges, and their use is not advised by CGDent.
Tetracycline and its derivative minocycline have historically been preferred due to their broad-spectrum nature, high concentration in gingival crevicular fluid, and their ability to inhibit collagenase activity. However, these drugs have been associated with increased bacterial resistance and potential side effects such as photosensitivity, gastrointestinal disturbances, and rare cases of irreversible tooth discoloration in children.
Clindamycin is another systemic antimicrobial used due to its excellent penetration into bone and soft tissue, as well as its efficacy against anaerobic bacteria. Yet its use should be limited due to the high risk of Clostridium difficile infection and associated pseudomembranous colitis, a potentially fatal condition. Additionally, clindamycin resistance has been observed among oral bacteria.
Co-amoxiclav, a combination of amoxicillin and clavulanic acid, is also used in managing periodontitis. Its efficacy lies in its broad-spectrum coverage and the ability of clavulanic acid to inhibit beta-lactamases, thereby enhancing the efficacy of amoxicillin. However, serious concerns exist about the development of resistance due to its widespread use and potential for severe side effects, including liver dysfunction.
The use (misuse?) of these alternative antibiotics underscores a broader global issue of antibiotic stewardship. While these antibiotics have potential (though minimal) benefits in treating periodontitis, their widespread use will contribute to the emergence of antibiotic-resistant bacterial strains.