Lack of evidence for the use of antibiotics in periodontics
Antibiotics have been an invaluable boon to mankind, saving millions of human lives during the recent 75 years. In the smaller scale of the dental profession they have undoubtedly saved a lot of teeth, too. Some of the most remarkable treatment results I have seen in my periodontal practice have been in patients who received antibiotics in addition to conventional periodontal treatment. On the other hand, the vast majority of periodontitis cases can be treated successfully without antibiotics, and we also have to consider the emerging problem with antibiotic-resistant bacteria.
Consequently, 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.
Recently I was involved in the elaboration of the Danish National Clinical Guidelines for use of antibiotics in dental practice, and when we came to periodontitis, we felt on safe ground. 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?
However, when the literature search was completed, we were baffled: No relevant studies were found! 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. In a recent commendable study from Oslo the patients underwent a 3-month pre-study hygiene phase, but even in this study lack of response to initial treatment in spite of good oral hygiene was not a criterion for entering the study.
So we still need a good clinical study on the effect of supplementary antibiotic treatment in periodontal patients with good oral hygiene who have failed to respond to ordinary periodontal treatment. I sincerely hope that some researchers in Scandinavia or elsewhere will take up the glove and initiate such a study.
Based on gut feeling I will continue to treat my patients according to the Scandinavian consensus. But I would feel a lot more comfortable, if that treatment were based on solid scientific evidence.