A Restrictive Approach to the Use of Antibiotics in Periodontics

According to Dr. Bjarne Klausen from Esbjerg, Danish National Clinical Guidelines for the use of antibiotics in dental practice had recently been finalized. See a quick guide here [pdf]. As regards periodontal infection, he writes,

We formulated a focused question that was in line with the Scandinavian consensus: Should prescription of antibiotics be considered in patients with sufficient oral hygiene, if their periodontal condition does not respond to conventional treatment?

Well, they did not find a single relevant study. How’s that? Isn’t it so that dozens if not hundreds of studies had been performed since the early discovery by Jørgen Slots in Copenhagen identifying an unidentified gram-negative rod in abundance in what was then localized juvenile periodontitis? Soon later it was clear that this bug was Actinobacillus (now Aggregatibacter) actinomycetemcomitans, and that it could best be targeted by systemic antibiotics in conjunction with traditional mechanical/surgical periodontal treatment. Soon after a couple of case series by  van Winkelhoff et al. in 1989 and 1992, Amoxicillin plus Metronidazole (the infamous “van Winkelhoff cocktail”) became extremely popular and has since then been mentioned in national guidelines for the treatment of severe periodontitis where A. actinomycetemcomitans could be found in abundance.

Despite the fact that any, in general reasonable, additional treatment is likely to have some additional,  albeit transient, beneficial effects on surrogate clinical outcomes such as clinical attachment level, I have criticized some arguments by proponents of adjunct antibiotic use, in particular as regards minimizing the need for periodontal surgery, on several occasions here on this blog. The current global threat by increasing numbers of resistant, to antibiotics, pathogens may soon prevent dentists from light-heartedly prescribing antibiotics for their patients who might indeed suffer from severe chronic or aggressive periodontitis (a vastly exaggerating term for a subpopulation of patients with the same disease but more rapid progression).

But anyway, how is it possible that the consultant to the Danish Health Authority on formulating national guidelines on the use of antibiotics in connection with dental treatment, Dr. Bjarne Klausen, now denies any evidence for benefits of systemic antibiotics in periodontitis?

Klausen explains,

at least among Scandinavian periodontologists, a consensus has evolved that antibiotics should only be used as a last resort in patients who do not benefit from ordinary treatment including oral hygiene instruction, scaling, root planing and possibly periodontal surgery. And we certainly do not prescribe antibiotics to patients who cannot brush their teeth properly. That is what the students are taught in the dental schools, and that is what most of us do in our clinics.

When the Danish committee applied the above focused question, it came as a surprise that actually no relevant study had addressed this principle.

You all know that there are dozens and dozens of randomized clinical trials on antibiotics in periodontal treatment. But the usual protocol in these studies is to take untreated patients directly from the street, classify them as either chronic or aggressive periodontitis, and enroll them in a treatment program supplemented with antibiotics or placebo.

That’s actually true. So, when searching for studies in which patients with excellent oral hygiene who had not responded as expected despite properly conducted conventional periodontal therapy consisting of scaling and root planing as well as surgical treatment for better access, there will be none. This is actually an interesting approach. Similarly restrictive search questions could have been applied for, say, adjunctive topical antibiotics, anti-inflammatory treatments, or laser or photodynamic therapy. Most of the available studies had shown some, albeit generally little, additional benefits over scaling and root planing alone, and many are thus promoted by companies and researchers supported by respective companies. There is often plenty of evidence albeit positive effects are small and must be regarded clinically irrelevant.

If respective adjunctive treatments were only to be tested after conventional treatments had failed, then there would currently be hardly any evidence in favor of these adjuncts at all. To conduct these studies would be difficult as well-complying patients with a high standard of oral hygiene could only be randomized after frustrating experiences of recurrent disease despite considerable efforts of the therapist. Note that some adjuncts had rather been marketed as alternative treatments with remarkable extra costs.

Anyway, the growing problem of antimicrobial resistances and a serious innovation gap since 1990 demand that dentists and in particular periodontists do not use antibiotics in the vast majority of their patients at all. Prescription must be restricted to serious and life-threatening conditions. Reducing the need for periodontal surgery (for proper debridement of  infrabony and furcational lesions) must not be an indication for adjunct antibiotics. Periodontal surgery remains the treatment of choice for access problems.

4 February, 2017 @ 8:59 am.

Last modified February 4, 2017.

 

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