When should I use antibiotics in Periodontitis management?

“Should all the severe cases of periodontitis treated with adjunctive antibiotics to improve clinical outcome?”

As a general rule, antibiotics when given after systematic periodontal debridement work only in patients with aggressive periodontitis, which is characterised by

• rapid destruction of periodontal support
• in genetically highly susceptible individual
• potentially combined with highly virulent bacteria within the biofilm.

With a due consideration of exceptional cases, it would be reasonable to say that most of these cases are in younger patients, i.e. patients with severe periodontitis in their early or late 20s, 30s, or early 40s.

After destroying the biofilm structure by subgingival debridement, it makes more sense to  consider adjunctive antibiotics and it can benefit these patients.  The prevalence of this form of periodontitis is very small and most cases are being treated in specialist practice due to rapid and unpredictable nature.  Provided the quality debridement is performed, adjunctive antibiotics provide clinical benefits.

A general characteristic associated with more common form of periodontitis, chronic periodontitis is that it is prevalent in age groups older than 35 years of age.  Studies have demonstrated that Chronic periodontitis (severe periodontitis in older patients) does not benefit from adjunctive antibiotic administration compared to thorough debridement.

In long term (3 to 5 years), none of the antibiotics or their combination, despite being adjunct to thorough debridement with good oral hygiene and regular maintenance failed to show any significant benefits in clinical results compared to what can be achieved by systematic debridement without any antibiotics.  Most studies with antibiotics are extending to six months or one year.  The studies that went longer than 3 years failed to show any clinical benefit of adjuctive use.

Now, coming back to the core question of use of azithromycin for periodontitis: Considering the risk of Azithromycin causing fatal arrhythmia, there is no sound support to administer Azithromycin in older individuals with known or unknown (not yet detected) cardiovascular risks.

I would like to emphasize again:

• The younger patients with advanced periodontitis would benefit from adjunctive antibiotics in short term
• Young patient that are in their late 20s or early 30s, they would be less likely to fall in the high risk category of Azithromycin
• Older patients with advanced periodontitis don’t benefit from the adjunctive antibiotics
• It seems that we do not have sound rationale to give Azithromycin in older patients while treating periodontitis (even if it is severe) considering the risks involved.
• Selection of antibiotics should be made upon thorough assessment of patient’s psychological willingness to comply with antibiotic intake.  The chronic and aggressive periodontitis can be treated and maintained without any antibiotics.