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Original Article

Evaluation of the role of antibiotics in


preventing postoperative complication
after routine periodontal surgery:
A comparative clinical study
Rosh Radhika Mohan, Dwarakanath Chinni Doraswamy, Ahad M. Hussain,
Gayatri Gundannavar, Shobha Krishna Subbaiah, Deepika Jayaprakash

Department of Abstract:
Periodontics, The Background and Objectives: Aim of this randomly controlled clinical study was to evaluate the role of
Oxford Dental College, antibiotics to prevent postoperative complications after routine periodontal surgery and also to determine whether
Bangalore, Karnataka, their administration improved the surgical outcome. Materials and Methods: Forty‑five systemically healthy
India patients with moderate to severe chronic periodontitis requiring flap surgery were enrolled in the study. They
were randomly allocated to Amoxicillin, Doxycycline, and control groups. Surgical procedures were carried out
with complete asepsis as per the protocol. Postoperative assessment of patient variables like swelling, pain,
temperature, infection, ulceration, necrosis, and trismus was performed at intervals of 24 h, 48 h, 1 week, and
3 months. Changes in clinical parameters such as gingival index, plaque index, probing pocket depth, and clinical
attachment level were also recorded. Results: There was no incidence of postoperative infection in any of the
patients. Patient variables were comparable in all the three groups. Though there was significant improvement
in the periodontal parameters in all the groups, no statistically significant result was observed for any group over
the others. Conclusion: Results of this study showed that when periodontal surgical procedures were performed
following strict asepsis, the incidence of clinical infection was not significant among all the three groups, and
Access this article online also that antibiotic administration did not influence the outcome of surgery. Therefore, prophylactic antibiotics for
patients who are otherwise healthy administered following routine periodontal surgery to prevent postoperative
Website:
infection are unnecessary and have no demonstrable additional benefits.
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Key words:
DOI:
10.4103/0972-124X.131327 Antibiotic, asepsis, complications, periodontal surgery
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INTRODUCTION measures like strict aseptic protocol, anti‑infective


measures like proper sterilization, disinfection,

P eriodontitis is a multifactorial disease


occurring as a result of complex
interrelationship between infectious agents
barrier techniques, and other measures should
be taken. If such measures are taken, there is a
very low rate of postoperative infection following
and host factors. Environmental, acquired, and periodontal surgery,[4] thereby obviating the need
genetic risk factors modify the expression of for using antibiotics as a prophylactic measure.
disease and may therefore affect the onset or However, in actual clinical practice, it has been
progression of periodontitis.[1] The hallmarks of observed that different types of antimicrobials
periodontal disease are destruction of connective are routinely prescribed following periodontal
tissue and bone loss which, if left untreated, may surgery.
eventually lead to tooth loss.
Few studies support the concept of rapid healing
Moderate to severe cases of chronic periodontitis and less discomfort when antibiotics are used.[5,6]
Address for may warrant periodontal surgical procedures.[2] On the other hand, many well‑conducted studies
correspondence: Of the various factors that affect the outcome have not supported the routine use of antibiotics
Dr. Rosh Radhika Mohan, of periodontal surgical procedures, the most after periodontal surgery and concluded that
797/B, 23rd Cross, 19th main, important aspect is prevention of infection during antibiotics should be used only when there is
HSR Layout, 2nd Sector, and following surgery. Sources of infection during a medical indication or when the infection has
Bangalore ‑ 560 102, surgery in oral cavity include: instruments, hands already set in.[2,7‑11]
Karnataka, India.
of surgeon and assistant, air of the operatory, and
E‑mail: roshrm@
yahoo.com patient’s perioral skin, nostrils, and saliva.[3] In India, dentists have been known to prescribe
antibiotics more than any other medical personnel,
Submission: 12‑04‑2013 As postoperative infection can have a significant which is based totally on empiricism without any
Accepted: 16‑10‑2013 effect on the surgical outcome, preventive protocol or rationale.[12,13] Indiscriminate use of

Journal of Indian Society of Periodontology - Vol 18, Issue 2, Mar-Apr 2014 205
Mohan, et al.: Current status on antibiotics after routine periodontal surgery

antibiotics carry the risk of development of gastrointestinal Surgical aseptic protocol and infection control measures
tract problem, colonization of resistant or fungal strains, All the periodontal surgical procedures were carried out in a
cross‑reaction with other drugs, allergies, and increased cost fumigated enclosed surgical room with restricted entry and
of treatment.[14] proper drainage and water supply system in place. Anybody
with any source of infection was not allowed to enter the
Presently, guidelines for the selection and administration room. All personnel assigned in the operating room practiced
of antibiotics as prophylaxis following surgery are lacking. standard presurgical procedures which included autoclaved
Hence, this particular study was undertaken to assess surgical gowns, head caps, masks, and separate in‑house
the incidence of clinical infection and role of antibiotics footwear.
in preventing infection in patients undergoing routine
periodontal surgery and its influence on the surgical Dental operatory tools, including dental chair, were cleaned
outcome. daily with a disinfectant (Bacillol 25). Exposed areas were
covered with aluminum foils. Disposable glasses and
MATERIALS AND METHODS autoclaved disposable suction tips were used along with
distilled water as water source.
In this randomly controlled clinical trial, 45 patients with
moderate to severe chronic periodontitis requiring flap surgery High‑volume evacuation suctions were used for decreasing
were recruited from the Department of Periodontics. The study the aerosol production. Spittoon and tumbler water lines
protocol was approved by the ethical committee. were flushed for at least 5 min before and after the surgical
procedure. All instruments to be used were precleaned,
Inclusion criteria segregated, and packed in autoclavable sealed pouches which
• Patients aged between 25 and 55  years with moderate to had chemical spore testing test strips attached to them and were
severe chronic periodontitis then autoclaved [Figure 1].
• Systemically healthy patients fit for periodontal surgery
• Patients with good oral hygiene maintenance. Operator and assistant performed a presurgical scrub with
a germicidal soap using vigorous friction before the surgical
Exclusion criteria procedure. Patient preparation was done with povidone
• Patients allergic to Amoxicillin and Doxycycline iodine presurgical facial scrub. Pre‑procedural mouthrinse
• Pregnant patients with 10 ml of 0.2% chlorhexidine was done. Proper barrier
• Smokers methods were used.
• Previous periodontal surgery done in the same area
• Antibiotic therapy taken 3 months prior to surgery. Surgical procedure
Surgical procedure was performed under local anesthesia
Forty‑five patients fulfilling the above‑mentioned criteria with 2% lignocaine containing adrenaline (1:200,000). Buccal
were allocated into three groups (Amoxicillin, Doxycycline, and lingual (palatal) surgical incisions were made and
and control groups). Informed consent was obtained from the mucoperiosteal flaps were elevated [Figures 2 and 3].
patients. Three weeks following phase I therapy, a periodontal
evaluation was performed to confirm the suitability of sites for Complete debridement of the surgical site and scaling and
periodontal flap surgery. root planing were done with ultrasonic device and hand
curettes [Figure 4]. Flaps were approximated with 3‑0 silk
The following parameters were measured at baseline and sutures [Figure 5]. Periodontal dressing was placed and
3 months following surgery: postoperative instructions were given [Figure 6]. Application
• Plaque index (Silness and Loe) of cold pack was not advised for patients belonging to any of
• Gingival index (Loe and Silness) the three groups post‑surgically.
• Probing pocket depth (PPD)
• Clinical attachment level (CAL) Postoperative care and evaluation
• Gingival recession (GR) Test and control group patients were instructed to continue
• Tooth mobility. the medication and were asked to abstain from brushing on
the surgical site for at least 2 weeks. Use of chlorhexidine
Patients from both test and control groups with persistent gluconate (0.2%) was advised for 1 min twice daily immediately
probing depths equal to or more than 5 mm in at least three 1 day after the surgery for 1 month. Patients were asked
teeth in a sextant were subjected to periodontal flap surgery to record the incidence of pain, swelling, and increase in
in a specially prepared surgical room setup. Antibiotics temperature, or any other associated adverse effect after
were started 1 day prior to surgery and continued for 5 days surgery which was graded as mild, moderate, or severe in
thereafter, wherein Group A patients were administered nature. These were recorded in a tabular chart at two intervals
Amoxicillin 500 mg three times a day and Group B patients in a day for up to 48 h after surgery.
were administered Doxycycline 200 mg as a loading dose and
100 mg thereafter. Group C patients were controls without Periodontal dressing and sutures were removed 1 week
any antibiotic prescription. Nonsteroidal anti‑inflammatory postoperatively and the operated area was evaluated for
drug (Ibuprofen 400 mg + Paracetamol 333 mg) thrice daily for healing, infection, and any signs of ulceration and necrosis
a minimum of 3 days was prescribed for all the three groups which were tabulated separately in the chart provided
after surgery. [Figure 7].

206 Journal of Indian Society of Periodontology - Vol 18, Issue 2, Mar-Apr 2014
Mohan, et al.: Current status on antibiotics after routine periodontal surgery

Figure 1: Armamentarium Figure 2: Preoperative probing depth (Group B)

Figure 3: Incision placed Figure 4: Flap reflection and debridement

Figure 5: Sutures placed Figure 6: Periodontal dressing placed

Statistical software, namely, SAS 9.2, SPSS 15.0, Stata 10.1,


MedCalc 9.0.1, Systat 12.0, and R environment ver. 2.11.1 were
used for the analysis of the data, and Microsoft Word and Excel
were used to generate graphs, tables, etc.

RESULTS

All the patients returned regularly for the maintenance


program, without any dropouts. None of the patients belonging
to Groups A and B developed any allergy or unfavorable
response to the drug, requiring discontinuation.
Figure 7: 1 Week postoperative photograph
Age and gender of patients
In order to avoid bias, all the post‑surgical measurements The age of the patients ranged between 21 and 60 years, with
were done by previously calibrated periodontists, who were a mean age of 38.27 years in Group A, 37.27 years in Group B,
blinded to the group to which the patient belonged. After the and 39.93 years in Group C, thereby demonstrating the age
third month, all post‑surgical parameters were recorded and match between the Groups. A total of 16 male patients and
evaluated. 29 female patients participated in the study [Graphs 1 and 2].

Statistical analysis Periodontal variables


Analysis of variance (ANOVA) was used to find the Plaque index
significance of the study parameters between three or more The plaque scores in all the groups were consistently
groups of patients. Chi‑square/Fisher’s exact test was used to maintained between 0.12 and 0.17 throughout the study. There
find the significance of study parameters on categorical scale was no statistically significant difference in the plaque scores
between two or more groups. between the groups [Graph 3].

Journal of Indian Society of Periodontology - Vol 18, Issue 2, Mar-Apr 2014 207
Mohan, et al.: Current status on antibiotics after routine periodontal surgery

Figure 8: Preoperative photograph (Group A) Figure 9: 3 months postoperative photograph (Group A)

Figure 10: Preoperative photograph (Group B) Figure 11: 3 months postoperative photograph (Group B)

Figure 12: Preoperative photograph (Group C) Figure 13: 3 Months postoperative photograph (Group C)

Gingival index However, no statistically significant difference in the probing


The mean gingival index in all the groups ranged from 0.05 depth reduction could be seen when the results were compared
to 0.26 at the end of the study period. Also, no statistically among the three groups.
significant intergroup difference was observed [Graph 4].
Clinical attachment level
Probing pocket depth The mean CAL in group A was 0.96 ± 0.18 mm preoperatively,
The mean PPD in the Amoxicillin group was 3.92 ± 0.58 mm which reduced to 0.51 ± 0.46 mm postoperatively [Graph 6],
preoperatively, which reduced to 2.48 ± 0.25 mm postoperatively whereas in Group B, these readings were 1.01 ± 0.19 mm
[Graph 5, Figures 8 and 9], whereas in Doxycycline group, the preoperatively and 0.60 ± 0.44 mm postoperatively [Graph 6].
probing depth reduced from 4.04 ± 0.47 mm preoperatively to
2.45 ± 0.28 mm postoperatively [Graph 5, Figures 10 and 11]. In the control group, the mean CAL reduced from 0.99 ± 0.20 mm
In the control group, the probing depth was 4.11 ± 0.51 mm preoperatively to 0.84 ± 0.15 mm postoperatively [Graph 6]. All
preoperatively, which reduced to 2.34 ± 0.69 mm postoperatively these reductions within the groups were statistically significant,
[Graph 5, Figures 12 and 13]. The reduction in probing depth but no difference was seen when the results were compared
in all the three groups was statistically highly significant. among the three groups.

208 Journal of Indian Society of Periodontology - Vol 18, Issue 2, Mar-Apr 2014
Mohan, et al.: Current status on antibiotics after routine periodontal surgery

Graph 1: Comparison of age distribution between the patients Graph 2: Comparison of gender distribution between the patients

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Graph 3: Comparison of mean plaque index between the three groups Graph 4: Comparison of mean gingival index between the three groups

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Graph 5: Mean probing depths between the three groups Graph 6: Mean clinical attachment level between the three groups

Patient variables Other findings


Temperature Patients were directed to report any other events such as
There was no statistically significant difference among the lassitude, body ache, gastric upset, diarrhea, and headache
different groups [Graph 7]. following surgery.

Pain Overall, there was no statistical significance between the groups


There was no statistically significant difference in the in any of the parameters listed above.
pain perception among the three groups, 24 h following
surgery. Post‑surgical evaluation done after 60 h showed DISCUSSION
that two patients in Group A and two in Group C had mild
pain [Graph 8]. Oral cavity, which harbors billions of microorganisms as their
natural habitat, is also influenced by a multitude of external
Postoperative swelling factors, leading to its susceptibility for infection. Though in
No statistically significant association was observed among the actual practice, only a minority of surgical procedures performed
groups at any of the time intervals [Graph 9]. in the oral cavity result in any significant post‑surgical infection,
they could result in needless complications, discomfort to the
Other parameters patient, delay in healing, and can influence the final outcome
None of the patients in any group showed signs of postoperative as well. Hence, majority of the surgeons throughout the world
infection, and overall healing was satisfactory [Graph 10]. believe in the dictum “to err on the side of safety” and routinely

Journal of Indian Society of Periodontology - Vol 18, Issue 2, Mar-Apr 2014 209
Mohan, et al.: Current status on antibiotics after routine periodontal surgery

Graph 7: Comparison of incidence of temperature between the three groups

Graph 8: Comparison of incidence of pain between the three groups

Graph 9: Comparison of incidence of swelling between the three groups

prescribe antimicrobials as prophylaxis to prevent post‑surgical system prevailing in different parts of the world to guide
infections. Periodontists are no exception to this. periodontists regarding the type of drug, its dosage, duration,
etc. Literature support for routine antibiotic prescription is
However, there are neither guidelines nor incontrovertible lacking and few studies carried out to address this matter have
evidence to support this practice; also, there is no uniform provided different conclusions. Hence, as of now, prescribing

210 Journal of Indian Society of Periodontology - Vol 18, Issue 2, Mar-Apr 2014
Mohan, et al.: Current status on antibiotics after routine periodontal surgery

Graph 10: Comparison of incidence of other parameters between the three group

antimicrobial therapy as prophylaxis to prevent infection Studies in which randomized controlled trials (RCTs) were
during routine periodontal surgery can only be called as conducted reported that selective antimicrobial agents when
empirical and is not based on solid evidence. used as adjunctive to periodontal surgical procedures improved
the periodontal parameters,[19‑21] whereas meta‑analysis studies
This study, therefore, envisaged to evaluate the effects of reported that adjunctively used systemic antimicrobials did
antimicrobial prophylaxis on all the parameters of healing not show statistically significant results.[18,22‑24] However, in this
following periodontal surgery as compared to no drug study, there was no difference in the periodontal parameters
therapy, besides attempting to find out the actual incidence such as plaque index, gingival inflammation, pocket depth
of post‑surgical infections. The patients recruited were all reduction, or CAL among the different groups.
systemically healthy, belonged to a comparable age range, and
were compliant. Oral hygiene maintenance was periodically Hence, this study has clearly demonstrated that routine
reinforced and assessed by clinical parameters from baseline periodontal surgery when properly performed does not result
to 1 month prior to the surgery. Patients who did not maintain in post‑surgical infection and produces beneficial outcome
adequate oral hygiene and who were noncompliant were regardless of whether prophylactic antimicrobials have been
not included in the study as literature reviews have shown prescribed or not.
that noncompliant subjects had the highest risk of recurrent
periodontitis, even if they had completed the treatment plan. In this era where antimicrobials are being prescribed without
The surgical technique and the type of periodontal defects any basis, it often leads to abuse and misuse of them. The
were also standardized. development of various resistant strains of microorganisms
has frequently resulted in serious unmanageable infections.[25]
Results of the study clearly showed that properly performed Hence, the outcome of this study is very significant, particularly
periodontal surgery does not result in post‑surgical infection in a country like India where there is no antibiotic policy
or any complications. This was amply substantiated by lack prescribed by the regulatory bodies.
of any undesirable outcome such as persistent excessive pain,
severe swelling, abscess formation, ulceration, and necrosis in But it should be understood that this study was carried out
any of the patients. None of the patients had any noticeable in a hospital setting with a strong surgical protocol. Whether
systemic effect following surgery. These results correspond the same result can be obtained in an ordinary clinical setting,
with the reported results of the studies done earlier,[2,7‑10] but especially in a dental clinic setup, is questionable. Further
literature review has supported the potential beneficial effects of studies are required to be done in less than ideal settings before
prophylactic antibiotics in patients with systemic involvement. it can be unequivocally recommended to discontinue the use
of prophylactic antimicrobial drug following periodontal
Amoxicillin and Doxycycline were chosen for the two surgical procedure.
experimental groups, mainly because most of the dental
practitioners prefer Amoxicillin whereas majority of the CONCLUSION
periodontists prefer Doxycycline for its effect against
periodontal pathogens due to convenience of its usage, which The results of this study revealed that periodontal surgery done
thereby improves patient compliance. Metronidazole was not under strict surgical protocol did not result in postoperative
considered, as patient compliance has been found to be poor infection, irrespective of whether antibiotics were prescribed
due to its side effects.[15] or not. Hence, it is concluded that prophylactic medication
of patients with antibiotics who are otherwise healthy
Different patient variables (ulceration or necrosis, signs of following routinely properly performed periodontal surgery
delayed healing, adverse systemic effects such as fever, malaise, is unnecessary and has no demonstrable additional benefits.
lassitude, etc.) indicated that there was no difference between
any of the groups. These findings are in agreement with those Further studies need to be conducted in different clinical
of earlier studies.[2,13,16] The role of antimicrobials in improving settings before recommending changes in the antibiotic policy
periodontal variables following surgery is controversial.[17,18] for surgical procedures.

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Mohan, et al.: Current status on antibiotics after routine periodontal surgery

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