antibiotics as the only therapy of untreated chronic periodontitis: a critical commentary

Letter to the Editor

Antibiotics as the only therapy ofuntreated chronic periodontitis:a critical commentaryWalter C, Weiger R. Antibiotics as the only therapy of untreated chronic periodontitis:a critical commentary. J Clin Periodontol 2006; 33: 938–939. doi: 10.1111/j.1600-051X.2006.01019.x.

Dear Editor,In recent issues of the Journal of

Clinical Periodontology, a discussionhas been initiated about the use ofantibiotics as an adjunct in periodontaltherapy or even as a sole measure in thetreatment of periodontal diseases (Mom-belli 2005, 2006, Haffajee 2006, Nee-dleman et al. 2006).

In general, the revival of controver-sies discussed in scientific journals inthe field of periodontology is highlyappreciated. There are several aspects,which should be added to the discussionon antibiotics in the treatment of perio-dontitis as well as to the paper by Lopezet al. (2006).

(1) Today, periodontitis has been classi-fied in a group of infectious diseasescalled biofilm diseases. A biofilm isbriefly defined as a complex bacterialstructure adherent to wet surfaces.From a clinical perspective it isimportant to recognize that this struc-ture protects the bacteria from theimmunesystem of the host as well asfrom antimicrobial agents. Therefore,a biofilm is a difficult therapeutictarget (Socransky & Haffajee 2002).In the field of periodontal microbiol-ogy, it has been demonstrated recentlythat several antibiotics need to bemuch higher concentrated to reachthe minimal inhibitory concentration(MIC) in a biofilm compared withmicroorganisms grown in a plank-tonic culture (Eick et al. 2004). Todate, the only predictable way todisturb the dental biofilm is by usingmechanical means.

(2) In developing countries, antibioticsare discussed for treatment of perio-dontitis as the only therapy andjustified by the intention ‘insteadof doing nothing’. In addition tothe periodontitist’s abilities to per-form the treatment, the successfulperiodontitis therapy depends on thepatient’s compliance to maintainsupragingival plaque control duringthe active phase of treatment and,particularly, in the long term.Antibiotic treatment depends on theregular intake of the prescribeddrugs. Based on the findings fromstudies on tuberculosis therapy indeveloping countries, the therapeu-tic response was not satisfactoryand resistant strains increased dra-matically. Therefore, in this parti-cular population ‘directly observedtreatment (DOT)’ has been recom-mended by the WHO. DOT is aform of drug therapy during whichthe patient takes every single doseof the medication under directobservation of health care staff(Soares et al. 2006). This treatmentapproach has also been discussedfor HIV positive patients (Stenzelet al. 2001). In order to preventantibiotic resistance due to perio-dontal therapy, DOT seems to bean interesting approach for patientsin need for antibiotic therapy.

(3) Antibiotic treatment as a sole oradjunctive therapy has been sug-gested as an effective treatmentfrom a strictly economic point ofview. However, the following aspectsmust be recognized: (i) the problem

of patient compliance (DOT?), (ii) theneed for mechanical biofilm disrup-tion as initial as well as repeatedmaintenance treatment, and (iii) theincreasing antibiotic resistance with afurther need for expensive develop-ment of more effective antimicrobialdrugs. Therefore, antibiotic treatmentas a sole therapy does not seem to bea low-cost approach to reach long-term periodontal health. Of course,the points mentioned above need tobe further evaluated within clinicaltrials or other analyses.

(4) In the study by Lopez et al., the useof antibiotics resulted in a reductionof subgingival bacterial counts,and it was concluded that this regi-men may be useful in controllinguntreated chronic periodontitis inpopulations without access to dentalcare. From a traditional point ofview, the conclusion of this studyis surprising. In the observed sub-jects, the mean probing depth andthe percentage of sites with PD4–6 mm as well as PD46 mm wasquite low and, therefore, the perio-dontitis may be classified as slightrather than moderate to advanceddisease severity. Supragingival scal-ing (SGS) has been performed by anexperienced periodontist using anultrasonic scaler on all teeth in twosessions of 45 minutes each. It canbe assumed that especially in siteswith slight and moderate pocketprobing depths, a subgingival bio-film will also be disturbed by SGS.Therefore, the treatment performedmight be an adjunctive antibiotic

Clemens Walter and Roland Weiger

Department of Periodontology,

Endodontology and Cariology, School of

Dentistry, University Basel, Switzerland

J Clin Periodontol 2006; 33: 938–941 doi: 10.1111/j.1600-051X.2006.01019.x

938 r 2006 The Authors. Journal compilation r 2006 Blackwell Munksgaard

therapy instead of a sole antibiotictherapy at least in these sites. More-over, there are significant differ-ences between the groups concern-ing percentages of sites with PD 4–6 mm and mean probing depth. Bothare higher, respectively deeper inthe test group than in the control.The fact that probing depth reduc-tion is generally more pronouncedin deeper pockets following mecha-nical periodontal treatment, favoursthe outcome in the test group. Someother aspects would be interesting toknow: What about differencesbetween the results in multi-rootedversus single-rooted teeth? Whatabout long-term stability of theresults – this aspect, however, wasnot possible to evaluate in the citedstudy for good ethical reasons.

The treatment of periodontitis includ-ing the establishment of adequate, self-performed supragingival plaque controlin combination with mechanical instru-mentation of the root surface and sup-portive therapy has been demonstratedto be successful in order to maintainperiodontal health for more than 20years (Axelsson et al. 2004). This treat-ment can be classified as the ‘‘goldstandard’’ of periodontal care. There-fore, any treatment alternative used indaily dental practise should be superiorto the gold standard and well proven inlong-term clinical trials. Above all, thisis true for those treatment modalities,which present certain side effects andpossibly affect the efficacy when used

subsequently as therapy for more severediseases. Based on the current under-standing and the limited evidence, inparticular for long-term periodontalhealth (Herrera et al. 2002, Haffajeeet al. 2003), we feel that adjunctiveantibiotics should be prescribed onlyfor a very limited collective of subjects– only for patients with specific clinicalfeatures, namely for those with aggres-sive forms of periodontal disease, inorder to prevent antibiotic resistancedue to periodontal therapy.

References

Axelsson, P., Nystrom, B. & Lindhe, J. (2004)

The long-term effect of a plaque control

program on tooth mortality, caries and perio-

dontal disease in adults. Results after 30 years

of maintenance. Journal of Clinical Perio-

dontology 31, 749–757.

Eick, S., Seltmann, T. & Pfister, W. (2004)

Efficacy of antibiotics to strains of period-

ontopathogenic bacteria within a single spe-

cies biofilm – an in vitro study. Journal of

Clinical Periodontology 31, 376–383.

Haffajee, A. D. (2006) Systemic antibiotics: to

use or not to use in the treatment of perio-

dontal infections. That is the question. Jour-

nal of Clinical Periodontology 33, 359–361.

Haffajee, A. D., Socransky, S. S. & Gunsolley,

J. C. (2003) Systemic anti-infective perio-

dontal therapy. A systematic review. Annals

of Periodontology 8, 115–181.

Herrera, D., Sanz, M., Jepsen, S., Needleman, I.

& Roldan, S. (2002) A systematic review on

the effect of systemic antimicrobials as an

adjunct to scaling and root planing in perio-

dontitis patients. Journal of Clinical Perio-

dontology 29 (Suppl. 3), 136–159.

Lopez, N. J., Socransky, S. S., DaSilva, I., Japlit,

M. R. & Haffajee, A. D. (2006) Effects of

metronidazole plus amoxicillin as the only

therapy on the microbiological and clinical para-

meters of untreated chronic periodontitis. Jour-


Mombelli, A. (2005) Focused perspective on

van Winkelhoff. Journal of Clinical Perio-


Mombelli, A. (2006) Heresy? Treatment of

chronic periodontitis with systemic antibio-

tics only. Journal of Clinical Periodontology

33, 661–662.

Needleman, I., Wisson, M. & Van Winkelhoff,

A. J. (2006) Letter to the Editor. Journal of

Clinical Periodontology 33, 157.

Soares, E. C., Pacheco, A. G., Mello, F. C.,

Durovni, B., Chaisson, R. E. & Cavalcante,

S. C. (2006) Improvements in treatment

success rates with directly observed therapy

in Rio de Janeiro city. International Journal

of Tuberculosis and Lung Diseases 10,

690–695.

Socransky, S. S. & Haffajee, A. D. (2002)

Dental biofilms: difficult therapeutic targets.

Periodontology 2000 28, 12–55.

Stenzel, M. S., McKenzie, M., Mitty, J. A. &

Flanigan, T. P. (2001) Enhancing adherence

to HAART: a pilot program of modified

directly observed therapy. AIDS Read 11,

317–318.

Yours sincerely

Clemens Walters and Roland Weiger

Address:

Clemens Walter

Department of Periodontology

Endodontology and Cariology

School of Dentistry

University Basel

Hebelstrasse 3, CH-4056 Basel

Switzerland

E-mail: [email protected]

Letter to the Editor 939

r 2006 The Authors. Journal compilation r 2006 Blackwell Munksgaard

Letter to the Editor

ResponseLopez NJ, Socranksy, SS, Da Silva I, Japlit MR, Haffajee AD. Response. J ClinPeriodontol 2006; 33: 940–941. doi: 10.1111/j.1600-051X.2006.01023.x.

Dear Editor,We would like to thank Drs. Walter

& Weiger (2006) and Dr. Feres-Filhoet al. (2006) for their comments regard-ing our paper that was published in theSeptember issue of the Journal of Clin-ical Periodontology. We agree withDr. Walter that the discussion of con-troversial topics, such as the use ofsystemic antibiotics to treat periodontalinfections, provides different points ofview that can help to clarify the issues.To add to the discussion, we would liketo comment on the points raised in bothletters to the Editor.

1. The subgingival biofilm needs to be me-chanically removed or disturbed in orderfor systemic antibiotics to be effective.

The evidence that antibiotics need tobe in higher concentrations to reach theminimum inhibitory concentration in abiofilm was derived from in vitro studiesusing primarily cultures of single bac-terial species. This situation is quitedifferent from that which occurs innaturally occurring subgingival bio-films. Thus, the results of in vitro studiescannot be readily extrapolated to thein vivo situation. Our study demon-strated that the systemic administrationof metronidazole plus amoxicillin(M1A), without disturbing the subgin-gival biofilm by mechanical means,provided clinical and microbiologicalimprovements similar to those obtainedwith scaling and root planing (SRP)alone (Lopez et al. 2006). Thus, itappears that it is not essential tomechanically disrupt the subgingivalbiofilm in order for M1A to be effec-tive. This finding has been previouslydemonstrated in patients with chronicperiodontitis who received only M1Aand no additional periodontal therapyduring a 12-month study (Lopez &Gamonal 1998, Lopez et al. 2000).However, studies where systemicallyadministered antibiotics were used incombination with mechanical disruptionof the biofilm (i.e. SRP), the clinical and

microbiological outcomes were signifi-cantly better than those achieved bySRP alone (Herrera et al. 2002, Haffajeeet al. 2003). Therefore, mechanical dis-ruption of the subgingvial biofilm canpotentiate the antibiotic effect.

2. Antibiotic resistance and patientcompliance.

Antibiotic resistance can occur anytime an antibiotic is administered and isprobably more likely to occur if thepatient is not compliant with the drugadministration protocol. The antibiotictreatment of tuberculosis cited by Drs.Walter and Feres-Filho is somewhatdifferent from the treatment of perio-dontal infections, in that the antimicro-bial agents to treat tuberculosis areadministered over several months.Long-term administration of any medi-cation is likely to produce lower com-pliance rates. In our study M1A, givento control periodontal infections, wereprescribed for 7 days and compliancewas more predictable than in the situa-tion where long-term drug administra-tion was employed. However, the issueof antibiotic resistance including theimpact of patient compliance on theselection of new antibiotic resistantbacterial strains is extremely importantand warrants further investigation.

3. Dr. Walter suggested that antibio-tics as the sole therapy for periodontalinfections may not be a low-costapproach to reach long-term periodontalhealth. We agree with Dr. Walter thatthis may be the case. However, the costeffectiveness together with the clinicaleffectiveness of different periodontaltherapies need to be compared in rando-mized clinical trials.

4. Both letters commented that thesystemically administered antibioticsemployed in our study were not theonly treatment as supragingival plaqueremoval was performed before baselinemeasurements and at the 3-month mon-itoring visits. Dr. Feres-Filho also citedstudies in the literature where repeated,

professional supragingival plaqueremoval had led to significant changesin the subgingival microbiota. In ourstudy, there was the possibility that thesubgingival biofilm was disturbed bysupragingival scaling and this possibilitywas indicated in the discussion. How-ever, it is highly unlikely that the level ofsupragingival plaque removal performedin the current study could have led to theobserved clinical and microbiologicalchanges. In the study of Ximenez-Fyvieet al. (2000), for example, the significantdecreases in the mean counts of subgin-gival species was brought about by pro-fessional supragingival plaque removalperformed each week for 12 weeks. Thatregimen was much more intensive thanthe 3-monthly cleanings performed inour study. Further, the studies of Lopez& Gamonal (1998) and Lopez et al.(2000), cited above, demonstrated a sig-nificant clinical improvement and reduc-tion in the number of sites harboring P.gingivalis and P. intermedia after theadministration of M1A without addi-tional periodontal intervention and with-out changing the oral hygiene habits ofpatients. Nonetheless, the notion that thetreatment performed in the test group inour study may be considered to be anti-biotic therapy as an adjunct to supragin-gival plaque removal is plausible andmay be the correct interpretation.

5. The question regarding differencesbetween the results at multi-rooted versussingle-rooted teeth posed by Dr. Walter isintriguing and we will examine these datawith the possibility of presenting thefindings in a future publication.

As indicated in the letters, and statedin the discussion of our paper, there are anumber of issues that need to beaddressed regarding the use of antibioticsto treat periodontal infections. Many ofthese issues were discussed by Haffajee(2006) in a letter to the editor. In parti-cular, it is critical to weigh the benefitsand drawbacks of antibiotic therapy fordifferent subject groups and in different

Nestor J. Lopez1, Sigmund S.Socransky2, Isabel Da Silva1, MicheleR. Japlit2 and Anne D. Haffajee2

1Department of Conservative Dentistry,

Faculty of Dentistry, University of Chile,

Santiago, Chile; 2Department of Periodon-

tology, Forsyth Dental Institute, Boston, MA,

USA

940 Letter to the Editor


clinical settings. Nonetheless, our studyindicated that ‘‘occasional’’ professionalsupragingival plaque control and theadjunctive administration of M1A waseffective in controlling periodontal infec-tions for up to 12 months in patients withuntreated chronic periodontitis.

References

Feres-Filho, E., Silva, C. E., Giovannetti-

Menezes, N., Torres, M. C., Leao, A. T. T. &

Sansone, C. (2006) Letter to the editor. Jour-


Haffajee, A. D. (2006) Systemic antibiotics: to

use or not to use in the treatment of perio-

dontal infections. That is the question. Jour-


Haffajee, A. D., Socransky, S. S. & Gunsolley,

J. C. (2003) Systemic anti-infective perio-

dontal therapy. A systematic review. Annals

of Periodontology 8, 115–181.

Herrera, D., Sanz, M., Jepsen, S., Needleman, I.

& Roldan, S. (2002) A systematic review on

the effect of systemic antimicrobials as an

adjunct to scaling and root planing in perio-

dontitis patients. Journal of Clinical Perio-

dontology 29 (suppl. 3), 136–159.

Lopez, N. J. & Gamonal, J. A. (1998) Effects of

metronidazole plus amoxicillin in progressive

untreated adult periodontitis: results of a

single one-week course after 2 and 4 months.

Journal of Periodontology 69, 1291–1298.

Lopez, N. J., Gamonal, J. A. & Martinez, B.

(2000) Repeated metronidazol and amoxicil-

lin treatment of periodontitis. A follow-up

study. Journal of Periodontology 71, 79–89.

Lopez, N. J., Socransky, S. S., Da Silva, I.,

Japlit, M. R. & Haffajee, A. D. (2006) Effects

of metronidazole plus amoxicillin as the only

therapy on the microbiological and clinical

parameters of untreated chronic periodontitis.

Journal of Clinical Periodontology 33,

648–660.

Walter, C. & Weiger, R. (2006) Letter to the

editor. Journal of Clinical Periodontology

33, 938–939.

Ximenez-Fyvie, L. A., Haffajee, A. D., Som, S.,

Thompson, M., Torresyap, G. & Socransky,

S. S. (2000) The effect of repeated profes-

sional supragingival plaque removal on the

composition of the supra- and subgingival

microbiota. Journal of Clinical Perio-


Yours sincerely

N. J. Lopez, S. S. Socranksy,I. Da Silva, M. R. Japlit &A. D. Haffajee

Address:

Nestor J. Lopez

Department of Conservative Dentistry

University of Chile

Santiago

Chile

[email protected]

Letter to the Editor 941


antibiotics as the only therapy of untreated chronic periodontitis: a critical commentary

Documents