Systemic Antibiotics for Periodontal Diseases

June 24, 2014

2470

Contents

Periodontal disease can be caused by a number of factors including plaque and bacteria, genetics and smoking. Before even considering antibiotics to treat forms of periodontal disease, it must be remembered that:

Treatment RELIES on patient co-operation and their home-care
Non-surgical treatment, i.e. root surface debridement (RSD), must be considered first
Surgical treatment may need to be considered at some point

When?

Systemic antibiotics are only ever an adjunct to the above treatments and they should never be used on their own. Situations in which they may be used include:

Disease formally referred to as ‘Aggressive Periodontitis’
Acute Necrotising Ulcerative Gingivitis/Periodontitis
Periodontal Abscesses
(Guided tissue regeneration)

The options

The options for antimicrobial that we use include:

Azithromycin
Tetracyclines
Metronidazole
Amoxicillin (usually prescribed with metronidazole)

Treatment

Always consult a BNF (or equivalent drug formulary) if you are unsure with dosages. The following dosages/drugs are ones that I have been taught and picked up – caution should be advised!

Periodontitis formally referred to as ‘Aggressive Periodontitis’

Since the updated periodontology classification, ‘aggressive periodontitis’ is no longer an official diagnosis and this is likely to be periodontitis with molar-incisor pattern or grade C – careful assessment needs to be carried out however, as it will be age dependent. Essentially, it is still periodontitis that is out of proportion to local factors.

The latest guidance is to prescribe either:

First line – Amoxicillin 500mg, TDS for up to 5 days and Metronidazole 400mg, TDS for up to 7 days. A shorter duration reduces the risk of side effects and resistance.
Second line – Azithromycin 500mg, OD for 3 days. The drug has a long half life and so remains in the system longer, as well as being easier for a patient to be compliant with. An issue with Azithromycin is the potential interaction with statins and subsequent development of rhabdomyolysis. Therefore, it is advised that if the patient is on statins then the GP should be consulted to decide on whether the statins can be stopped for a few day.

Periodontal Abscess

The ideal situation with an abscess is to achieve some form of drainage, and with periodontal abscesses, often this can be achieved by RSD in the pockets surrounding the abscess. However, antibiotics may be given in some situations i.e. if there is systemic involvement or spreading infection. Drugs that may be prescribed include:

Azithromycin
Metronidazole
Co-amoxiclav

Acute Necrotising Ulcerative Gingivitis/Periodontitis (ANUG/P)

The standard treatment regime for this involves prescribing the patient metronidazole 400mg TDS for 3 days, hydrogen peroxide/chlorhexidine mouthwash and going through thorough oral hygiene instruction. This is because these are usually associated with anaerobic bacteria.

Advantages of Antibiotics

Evidence shows they work in certain conditions e.g. Aggressive Periodontitis
Target multiple sites easily
Low overall cost
Less clinical time needed to treat

Disadvantages of Antibiotics

Major unwanted side effects, especially gastrointestinal
Increased antibiotic resistance
Allergies
Heavily reliant on patient compliance

Summary

Antibiotics should only be used as an adjunct to treatment in periodontal diseases
Options include metronidazole, azithromycin and amoxicillin
Dosages and regimes vary between different conditions