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Clinical Practice Guidelines No.2021-001 : Antimicrobial / Antibiotics in Periodontal Therapy

CLINICAL PRACTICE GUIDELINES

TITLE : Antimicrobial / Antibiotics in Periodontal
Therapy
EFFECTIVE DATE : June 25, 2021
CPG NO. : 2021-081

1. STATEMENT OF PURPOSE
1.1 Define the types of antimicrobial and the indications of using them in periodontal therapy

2. REVISION HISTORY
Date Rev. Change
No.
Shaa.2 1442 AH (March 14, 2021) V.1 New

3. RELATED DOCUMENTS
3.1 NA

4. RELATED ACCREDITATION STANDARDS

4.1 NA

5. DEFINITIONS
5.1 Antimicrobial Agents it is a chemotherapeutic agent that acts by reducing the number of
bacteria present.
5.2 Types of anti-infective or antimicrobial therapy used in periodontal diseases:
5.2.1 Antiseptic is an agent that, applied to living tissues, is able to prevent or arrest the
growth or action of microorganisms. (see CPG no).
5.2.2 Antibiotics:
5.2.2.1 Systemic antibiotic is a substance (medication) administered orally to
destroy or inhibit the growth of microorganism.
5.2.2.2 Local antibiotic is an Antimicrobial locally placed in periodontal pocket with
delivery system and released in a controlled manner allowing a minimum
inhibitory concentration.
5.2.3 Host Modulation is a low dose antibiotic which can inhibit of matrix metalloproteinases
that have been implicated in the plaque-induced pathologic degradation of connective
tissue collagen of the periodontal supporting structures A drug has been approved by
the United States Federal Drug Administration for use as an adjunct to scaling and root
planning for treatment of chronic periodontitis.

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Clinical Practice Guidelines No.2021-001 : Antimicrobial / Antibiotics in Periodontal Therapy

5.3 ASA (American Society of Anesthesiologists) Classification scores:

5.3.1 ASA I : Normal healthy patient.
5.3.2 ASA II : A patient with a mild systemic disease.
5.3.3 ASA III : A patient with severe systemic disease limiting activity but not incapacitating
5.3.4 ASA IV : A patient with incapacitating disease that is a constant threat to life.

6. POLICIES
6.1 Antibiotic therapy in periodontics aims to reinforce mechanical treatment and to support host
defenses in overcoming periodontal infections by killing subgingival pathogens that remain after
periodontal instrumentation.
6.2 Modifications based on patient’s ASA Score:
6.2.1 ASA I: Depend according to the case diagnosis and finding
6.2.2 ASA II: Depend on the case diagnosis, finding , risk factors and medical condition
6.2.3 ASA III: Limited treatment to the emergency, Depend on the case diagnosis, finding ,
risk factors and medical condition
6.2.4 ASA IV: contraindicated, needs hospital in case of emergency.

7. PROCEDURES
7.1 Local Antibiotic
7.1.1 3 different types of local delivery antibiotics used in this procedures, there are Arestin
(1mg Minocycline Microsphers); Atridox (10% Doxycycline hyclate); and PerioChip (2.5
mg chlorhexidine in gelatin matrix).
7.1.2 Indication used in combined with scaling and root planning in the following situations
isolated forms of periodontitis (pocket more than 5mm) with bleeding on probing; Non-
responding; and recurrent sites.
7.1.2.1 Step 1: Do a scaling and root planning the pocket first then irrigation of the
site.
7.1.2.2 Step 2 : Dry then do proper isolation of the site.
7.1.2.3 Step 3 : Deliver the medications according to the manufacture instruction of
each type.
7.1.2.4 Step 4 : Post-operative instruction.

7.2 Clinical Significance

7.2.1 Systematic reviews report that modest additional propping depth (PD) reductions in the
range of .25mm to .5mm when used as adjunct to SRP in pocket >5 mm.
7.2.2 The decision to use local anti‐infective adjunctive therapy remains a matter of
individual clinical judgment, the phase of treatment, and the patient's status.of 8
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Clinical Practice Guidelines No.2021-001 : Antimicrobial / Antibiotics in Periodontal Therapy

7.3 Systemic Antibiotic

7.3.1 Most Common Indications:
7.3.1.1 Periodontitis: Antibiotic therapy is usually recommended for patients showing
progressive periodontal breakdown even after conventional mechanical
treatment, patients not responding to periodontal therapy (refractory
periodontitis) and patients with recurrent disease.
7.3.1.2 Rapid destruction and progression and early onset disease which
disproportioned to the biofilm deposition.
7.3.1.3 Necrotizing periodontal diseases: Patients with moderate or severe NUG or
necrotizing ulcerative periodontitis (NUP), local lymphadenopathy and systemic
involvement need antibiotic therapy.
7.3.1.4 Periodontal abscess: Antibiotic therapy is indicated for periodontal abscesses
with systemic manifestations (fever, malaise, and lymphadenopathy).
Antibiotics for the treatment of abscesses should be prescribed in conjunction
with surgical incision and drainage.
7.3.1.5 Patients having uncontrolled diabetes, organ transplantation, bone marrow
transplantation leukemia, neutropenia, thrombocytopenia are at greater risk of
developing infection after dental procedures due to immunosuppression or
decreased number of immune cells.
7.3.1.6 Prophylaxes antibiotic for : Chronic renal disease patients , patients having
previous history of infective endocarditis, prosthetic cardiac valves, major
congenital heart disease (tetralogy of Fallot, transposition of great arteries,
surgically constructed systemic pulmonary shunts or conduits), acquired
valvular function (e.g., rheumatic heart disease), hypertrophic cardiomyopathy,
mitral valve prolapsed with valvular regurgitation, thickened leaflets or both.
7.3.1.7 Other Possible Indications for using Antibiotics
7.3.1.7.1 Smokers
7.3.1.7.2 Patient that can’t afford the surgical treatment
7.3.1.7.3 Implant (CPG no …..)
7.3.1.7.4 Regeneration Therapy (CPG no ……)
7.4 Clinical Steps
7.4.1 Initial periodontal therapy should include thorough mechanical root debridement
followed by surgical access if needed.
7.4.2 Antibiotics may be prescribed on the basis of the clinical need for further treatment, and
the medical status and current medications of the patient.
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Clinical Practice Guidelines No.2021-001 : Antimicrobial / Antibiotics in Periodontal Therapy

7.4.3 The clinical response should be evaluated 1 to 3 months after completion of the
mechanical therapy. If periodontal disease appears to progress or if inflammation does
not resolve, a microbiological examination of the subgingival microbiota may help
determine the presence and amount of remaining putative periodontal pathogens.
7.4.4 After resolution of the inflammation patient needs to be in a maintenance program.

7.5 Host modulation therapy (Periostat)

7.5.1 Indication can be used in combination with scaling and root planning for periodontitis
patients.
7.5.1.1 Low dose doxycycline hyclate 20mg (Periostat), when taken every 12 hours
for 3 months.

8. APPENDICES
8.1 Common antibiotic Therapies in treatment of periodontal disease, adverse reactions and drug
interactions.
8.2 2017 American heart association recommendation regimen for the antibiotic prophylaxis.

9. REFERENCES
9.1 Lindhe. J Clinical Periodontology and Implant Dentistry Text book, 5th Ed. Blackwell
Munkssgaard, 2008. Oxford.
9.2 Position Paper: Systemic Antibiotics in Periodontics. J Periodontol 2004;75:1553‐1565.
9.3 Slots J, Ting M. Systemic antibiotics in the treatment of periodontal disease. Periodontol 2000.
2002;28:106-76. doi: 10.1034/j.1600-0757.2002.280106.x. PMID: 12013339.
9.4 Haffajee , S. Socransky , Systemic Anti‐Infective Periodontal Therapy. A Systematic Review,
Ann Periodontol 2003;8:115‐181.
9.5 Greenstein G. Efficacy of sub antimicrobial dose doxycycline in the treatment of periodontal
disease .A critical evaluation Int J periodontics Restorative Dent 2004.

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Clinical Practice Guidelines No.2021-001 : Antimicrobial / Antibiotics in Periodontal Therapy

PREPARED BY:

DR. DALIA NOURAH

Assistant Professor
Umm Al-Qura University Department of Periodontics

REVIEW OF REGULATORY DOCUMENTS DEPT.:

REVIEWED BY:

PROF. FATIN ARAB AWARTANI

Position
Department
Date of Signature

APPROVED BY:

DR. ADNAN AL MAGHLOUTH

Consultant
Head of the Publication Committee
Date of Signature

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Clinical Practice Guidelines No.2021-001 : Antimicrobial / Antibiotics in Periodontal Therapy

APPENDIX 8.1

Common Daily Adult

Antibiotic Adverse Oral Dose Drug interactions Effect
Reaction (Average)
Metronidazole Nausea / 500mg b.i.d or  Barbiturates  Decreased effectiveness of
vomiting t.i.d / 8 days metronidazole
 Oral anticoagulant  Increased anticoagulant effect
( warfarin)
 Ethanol ( alcohol)  Disulfiram-like (antabuse)
reaction
Clindamycin Diarrhea 300mg t.i.d /8  Anti-diarrheals  Decreased absorption of
days clindamycin
 Muscle relaxants  Increased frequency and
(diazepam) duration
 Erythromycin  of respiratory paralysis Mutual
antagonism
Penicillin Hypersensitivity / 250mg -
Increased levels of penicillin
diarrhea 500mg t.i.d / Probenecid
Increased level of penicillin
8 days
Tetracycline Photosensitivity 200mg q.d/ 21  Antacids, aluminum,  Decreased absorption of
(doxycycline ) days bismuth, iron, Mg++ tetracyclines due to chelation
 Barbiturates and  Decreased serum half-life of
hydantoins doxycycline
 Carbamazepine (Tegretol)  Decreased serum half-life of
 Digoxin doxycycline
 Increased serum levels of
digoxin
Azithromycin Diarrhea 250mg-500mg  Carbamazepine Cisapride
q.d/ 4-7 days  Cyclosporin
Methylprednisolone Non-  Increased serum levels of the
sedating antihistamines medication ( toxicity )
Theophylline
 Oral anticoagulants  Increased anticoagulant effect
(warfarin)
Fluroquinolones Photosensitivity 500mg b.i.d /  Cations (Al+++, Ca++,  Decreased absorption of
(ciprofloxacin ) Diarrhea / 8 days Fe++, Mg++, Zn++) in fluoroquinolones due to
Achilles tendon antacids, vitamins, ad chelation
disorder dairy products
 Caffeine  Increased caffeine
Cimetidine concentration
Cyclosporin  Increased serum levels of the
Non-steroidal anti- medications
inflammatory drugs
 Probenecid  Decreased ciprofloxacin
 Sucralfate clearance
 Theophylline  Decreased absorption of
fluoroquinolones
 Increased serum levels of
theophylline
 Oral anticoagulants  Increased anticoagulant effect
(warfarin)

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Clinical Practice Guidelines No.2021-001 : Antimicrobial / Antibiotics in Periodontal Therapy

Common Daily Adult

Antibiotic Adverse Oral Dose Drug interactions Effect
Reaction (Average)
Combination
Therapy

Metronidazole + Hypersensitivity / 250mg

amoxicillin diarrhea/ nausea /t.i.d/8days of
/ vomiting each drug
Or 500mg for
each
If the patient has
allergy from
penicillin
Metronidazole + Photosensitivity 500 mg b.i.d
ciprofloxacin Diarrhea / /8 days of
Achilles tendon each drug
disorder

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Clinical Practice Guidelines No.2021-001 : Antimicrobial / Antibiotics in Periodontal Therapy

APPENDIX 8.2

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