Concerns about increasing antibiotic resistance (e.g., methicillin-resistant Staphylococcus aureus, multidrug-resistant tuberculosis, antibiotic resistance of bacteria causing common infections of the urinary tract, pneumonia, or bloodstream infections), which jeopardizes effective prevention and treatment of life-threatening infections should be taken seriously when considering adjunct antibiotic therapy of periodontal diseases. After all, periodontal infections are not life-threatening diseases and can usually be controlled without adjunctive antibiotics. Apart from generalized severe cases, chronic periodontitis should not be treated in the first place with adjunct systemic antibiotics. In cases of aggressive or refractory periodontitis, microbiological diagnosis may allow targeting specific pathogens such as Aggregatibacter actinomycetemcomitans or Porphyromonas gingivalis. Responsible use of antibiotics takes into account the possible development of bacterial resistance, antibiotic toxicity and the risk of sensitizing.
Moreover, reducing the need for periodontal surgery by adjunct antibiotics may be short-sighted (note that I had written about this on several occasions here on this blog). Anatomical defects such as furcation involvement and infrabony lesions, which are the main indications for periodontal surgery, won’t resolve after subgingival scaling and adjunct antibiotic treatment. In light of the global problem of antibiotic resistance, any recommendation for repeat courses of antibiotic therapy to reduce the need for minor surgical intervention in a not life-threatening disease should be considered inappropriate.
I have noted in the past couple of years a tendency of broadening the so far limited indication for adjunct systemic antibiotics for the treatment of chronic periodontitis. This is mainly due to systematic reviews with a special focused question on periodontal probing depth reduction and clinical attachment gain as outcome. New randomized controlled clinical trial have been published as well and have now discussed also an old concept, i.e. reducing the need for periodontal surgery. On the sad occasion of the demise of Walter J. Loesche I had emphasized that it was he, already in the 1980s, who had introduced this slightly provocative outcome.
One of the great microbiologists among us periodontists has passed away in October this year, Dr. Walter J. Loesche. An obituary by Richard Ellen and Dennis Lopatin is being published in Journal of Dental Research and for those who have access to JDR‘s web page the respective online version may be found here. One of Dr. Loesche’s papers [pdf] (together with current Editor of Journal of Periodontology, Kenneth Kornman), which had been published just after I had received my Dr. med. dent. degree, had dealt with the possible substitution of essential growth factor vitamin K (or an analogue menadione) for Bacteroides melaninogenicus subsp. intermedius (now Prevotella intermedia or rather P. nigrescens, as has recently been shown by Gürsoy et al.) by largely increased progesterone and estradiol in gingival crevice fluid during pregnancy providing an ecological advantage for this potential periodontal pathogen and similar bacteria such as B. melaninogenicus subsp. melaninogenicus (now P. melaninogenica) in the subgingival environment. Specific and ecological plaque hypothesis elegantly united.
The short series of articles by Kornman and Loesche on pregnancy gingivitis has always fascinated me as well-conducted multidisciplinary piece of research which seemingly shed bright light on a mystery well-known for millenniums in any culture: Why do pregnant women lose teeth? And still, I like entertaining the idea that this single paper may have sparked my interest in science.