Discussion on Antibiotic Use in Periodontitis Treatment

First, antibiotics are only an adjunctive therapy in our overall treatment sequence. Since they are adjunctive, they must be used in conjunction with debridement or surgery. Simply using oral or local medications (without surgical/non-surgical treatment) cannot be considered a treatment plan. This point is also unsupported from an evidence-based medicine perspective.

Secondly, there has always been controversy in this area, and no single drug or method has absolute superiority.

Systemic Local

Drug Distribution Wide Narrow, localized

Drug Concentration In various body parts High in treatment area,

Different Distribution Low in other areas

Treatment Efficacy Effective against broadly distributed Local efficacy

microbes more effectively Targeting bacteria related to plaque

Potential Issues Systemic adverse reactions Potential reinfection in non-treatment areas

Clinical Limitations Requires good patient compliance Requires infection to be limited to treatment area

It is effective. Whether in aggressive or chronic periodontitis, numerous clinical randomized controlled trials have shown that, when combined with non-surgical root surface debridement treatment, many broad-spectrum antibiotics can help in reducing the depth of periodontal pockets and increasing clinical attachment levels.

However, for chronic periodontitis, the difference in the degree of attachment level increase between the two groups (those using and not using antibiotics) is minimal. Some studies have found statistically significant data, but due to individual variability and experimental-related errors, it is challenging to conclude the absolute superiority of systemic medication.

First, if medication is to be used, timing is crucial.

Generally, the best effect of medication starts on the same day as the last round of root surface debridement.

1. If treating the entire mouth at once, the medication timing is the same day;

2. If debridement is done in two or four sessions, then medication should start after the fourth debridement session.

The currently favored method of medication internationally is:

“Cocktail” combination—Amoxicillin and Metronidazole.

(The method of drug configuration is similar to mixing cocktails, hence the name. It originated from multi-drug combination therapy for AIDS.)

Amoxicillin (500mg, t.i.d) + Metronidazole (400mg, t.i.d), for seven days.

This administration method has been applied in numerous clinical experiments. Research has shown that it is superior to other antibiotics or combinations in reducing periodontal pockets and increasing clinical attachment. In recent years, some scholars have attempted to use new antibiotics (such as Azithromycin) and found their effects to be “comparable” through experimental comparisons. I believe that more research, especially on the long-term follow-up effects, is still needed.

Secondly, for patients with aggressive periodontitis, systemic antibiotics are generally routinely used.

The bacterial ecology of aggressive periodontitis differs from that of chronic periodontitis. Clinically, the combination of Amoxicillin and Metronidazole is generally used, administered on the same day after root surface debridement, for one week. The efficacy has been supported by evidence-based medicine and can significantly increase post-operative clinical attachment levels.

Finally, the biggest issue with systemic antibiotics is the ‘concern about antibiotic overuse’ and individual resistance and adverse reactions. The issue of resistance has become a global concern. People have come to realize that antibiotics may disrupt the delicate ecological balance of the body, leading to the proliferation of non-bacterial microorganisms. This can result in new, more stubborn infections, making treatment more challenging. In our country, many clinical doctors lack caution regarding medication, and many patients lack basic knowledge about drugs. In the spirit of being responsible for patients, we should carefully select antibiotics.

Quoting a statement from Clinical Periodontology and Implant Dentistry:

Compared to systemic medication, local antibiotics have their advantages.

1. Clear target, directly targeting the microbial community within the periodontal pocket, maximizing drug concentration within the pocket.

2. Minimal impact on other organs in the body.

Compared to systemic medication, local medication is relatively costly. The most common local medication on the market in China is Minocycline-containing Periocline ointment【Product name: Periocline】. However, many experimental conclusions are that ‘the statistical advantages of this drug cannot be proven’. Therefore, further research is still needed.

The biggest challenge facing local medication is how to maintain the drug concentration over a prolonged period. Due to the continuous flushing of gingival crevicular fluid (GCF) within the pocket, even if the drug is effective, its concentration may decrease rapidly.

Studies comparing various local antibiotics found that Chlorhexidine chips【Product name: PerioChip】 and Tetracycline fibers【Product name: Actisite】 can effectively increase clinical attachment levels.

Chlorhexidine Chips:

Tetracycline Fiber Actisite®:

Click the link in the lower left corner of the article to access the product webpage.

The above drugs can remain in the pocket and continuously release the drug, thus having certain clinical effects. Additionally, 1% Chlorhexidine gel【Product name: CORSODYL】, due to its viscosity, can achieve better results if combined with an effective carrier to increase its retention in the pocket. However, these products do not seem to be available in the domestic market yet. If anyone has information on this, please feel free to leave a message for me.

Chlorhexidine Gel CORSODYL

1. Systemic medication for patients with aggressive periodontitis;

2. For severe chronic periodontitis patients, such as those diagnosed with extensive deep periodontal pockets (>7mm) accompanied by multiple periodontal abscesses, I also consider adjunctive medication; the purpose of the medication is to compensate for the inadequacies of root surface debridement and achieve greater clinical attachment levels, thereby reducing the likelihood of future periodontal surgery.

3. For patients who have previously received basic treatment but still have residual periodontal pockets, systemic medication is generally not used. If conditions allow, I consider using local antibiotics that can remain and release drugs in deep periodontal pockets (>7mm). At the same time, I take into account the patient’s systemic factors (e.g., immunodeficiency or poorly controlled diabetes) and use medications in a personalized and flexible manner to achieve the best clinical outcomes.

1. Mombelli A. Antimicrobial advances in treating periodontal diseases. In: Kinane DF, Mombelli A, editors. Frontiers of oral biology: periodontal disease. Basel: Karger AG,2012:133-148.

2. Matesanz-P_erez P, Garc_ıa-Gargallo M, Figuero E, Bascones-Mart_ınez A, Sanz M, Herrera D. A systematic review on the effects of local antimicrobials as adjuncts to subgingival debridement, compared with subgingival debridement alone, in the treatment of chronic periodontitis. J Clin Periodontol 2013: 40: 227–241.

3. Griffiths, G.S., Ayob, R., Guerrero, A. et al. (2011). Amoxicillin and metronidazole as an adjunctive treatment in generalized aggressive periodontitis at initial therapy or re‐treatment: a randomized controlled clinical trial. Journal of Clinical Periodontology 38, 43–49.

4. Kaner, D., Bernimoulin, J.P., Hopfenmuller, W., Kleber, B.M. & Friedmann, A. (2007a). Controlled‐delivery chlorhexidine chip versus amoxicillin/metronidazole as adjunctive anti- microbial therapy for generalized aggressive periodontitis: a randomized controlled clinical trial. Journal of Clinical Periodontology 34, 880–891.

5. Lang, N. P., & Lindhe, J. (Eds.). (2015). Clinical Periodontology and Implant Dentistry, 2 Volume Set. John Wiley & Sons. Chapter 43.

Copyright belongs to the author. For commercial reproduction, please contact the public account for authorization, and for non-commercial reproduction, please indicate the source.