Systemic Antibiotics in Periodontics*
This position paper addresses the role of systemic antibiotics in the treatment of periodontal disease. Topical antibiotic therapy is not discussed here. The paper was prepared by the Research, Science and Therapy Committee of the American Academy of Periodontology. The document consists of three sections: 1) concept ofantibiotic periodontal therapy; 2) efﬁcacy of antibiotic periodontal therapy; and 3) practical aspects of antibiotic periodontal therapy. The conclusions drawn in this paper represent the position of the American Academy of Periodontology and are intended for the information of the dental profession. J Periodontol 2004;75:1553-1565.
he microbial etiology of inﬂammatory periodontal diseasesprovides the rationale for the use of antimicrobial medication in periodontal therapy. As evidence for bacterial specificity in periodontitis has accumulated and strengthened over the past three decades, dentists have increased their use of systemic antibiotics in periodontal therapy. This concept is based on the premise that speciﬁc microorganisms cause destructive periodontal disease and that theantibiotic agent in vivo can exceed concentrations necessary to kill or inhibit the pathogen(s). Antibiotics are defined in this report as naturally occurring or synthetic organic substances that in low concentrations can inhibit or kill selective microorganisms. Antibiotics may be prescribed for periodontal patients who do not respond to conventional mechanical therapy, for patients with acuteperiodontal infections associated with systemic manifestations, for prophylaxis in medically compromised patients, and as an adjunct to surgical and non-surgical periodontal therapy. Antibiotic therapy for medical indications has been discussed elsewhere and will not be considered here.1,2 This position paper is concerned with the use of antibiotics in the treatment of periodontitis lesions. Theconcept of antibiotic periodontal therapy centers upon the pathogenic microbiota, the patient, and the drug. These issues are each addressed separately. PERIODONTAL PATHOGENS The most effective use of antibiotics for the treatment of periodontitis presupposes knowledge of the pathogenic microbiota. At least 500 bacterial taxa have
* This paper was prepared by the Research, Science and TherapyCommittee and approved by the Board of Trustees of the American Academy of Periodontology in August 2004.
been identiﬁed within periodontal pockets.3 However, relatively few species have been clearly associated with progressive periodontitis (Table 1). Most putative pathogens are indigenous to the human oral cavity, but possible superinfecting organisms (enteric Gramnegative rods, pseudomonas,staphylococci, yeasts) may also inhabit periodontal pockets. Periodontitis lesions usually harbor a constellation of putative pathogens rather than a single pathogenic species. Most putative periodontal pathogens are Gramnegative anaerobic rods. However, some pathogens are Gram-positive facultative and anaerobic cocci and rods and others are Gram-negative facultative rods. Putative periodontal pathogensvary considerably in sensitivity to several antibiotics making simplistic approaches to antimicrobial chemotherapy problematic.6 PATIENTS Prime candidates for systemic antibiotic therapy are patients who exhibit continuing loss of periodontal attachment despite diligent conventional mechanical periodontal therapy. Recurrent or refractory periodontitis is often related to persistent subgingivalpathogens and perhaps to impaired host resistance.7 Patients with aggressive types of periodontitis,8 or with medical conditions predisposing to periodontitis9 may beneﬁt from antibiotic therapy. Patients with acute or severe periodontal infections (periodontal abscess, acute necrotizing gingivitis/periodontitis) may also need antibiotic therapy.10 Patients with gingivitis or chronic periodontitis...