Antimicrobial medication

A review of evidence related to local antimicrobials* suggests that locally delivered chlorhexidine as an adjunct to subgingival instrumentation can lead to short-term improvements in periodontal pocket depths compared to subgingival instrumentation alone.⁷⁷ However, the improvements were small, no significant differences in clinical attachment levels were observed and there was insufficient data on bleeding and pocket closure. The certainty of the evidence is considered low due to significant heterogeneity, risk of bias and lack of data on the long-term effects of the intervention.

A review of evidence suggests that local antibiotics as an adjunct to subgingival instrumentation can lead to short-term improvements in periodontal pocket depths and clinical attachment levels compared to subgingival instrumentation alone.⁷⁷ However, long-term benefits were not evident and the clinical relevance of the small improvements observed is unclear. The certainty of the evidence is considered low due to risk of bias and significant heterogeneity, most likely due to the variation in active ingredients, application protocols and study designs. 

Based on these findings, the BSP implementation of European S3 – level evidence-based treatment guidelines for stage I-III periodontitis in UK clinical practice (BSP-S3)⁶ guideline recommends that specific locally administered sustained-release antibiotics and locally administered sustained release chlorhexidine as an adjunct to subgingival instrumentation in patients with periodontitis may be considered. These open/conditional recommendations reflect the uncertainty of the evidence.

However, due to the high risk of bias and heterogeneity observed in the majority of primary studies, the unclear clinical benefits of adjunctive local antimicrobial therapy and the unclear impact on antibiotic stewardship, the intervention is not recommended in this guidance for the routine care and management of patients with a diagnosis of periodontitis.

Further details on the development of the recommendations in this guidance can be found in Methodology.

*Note that these do not include active ingredients with antimicrobial activity that can be found in some toothpastes (e.g. stannous fluoride).

Systemic antibiotics, prescribed as an adjunct to non-surgical periodontal treatment, have been proposed to act by suppressing the bacterial species responsible for biofilm growth, leading to a less pathogenic oral environment. A review of evidence indicates that the adjunctive use of systemic antibiotics to treat periodontitis may result in clinically significant improvements to patient outcomes compared with those achieved by non-surgical periodontal treatment alone.⁷⁸ The certainty of the evidence is considered high due to low risk of bias, low heterogeneity and the high consistency of results from the included studies. However, it should be noted that almost all included studies were performed in a university setting and the observed improvements in outcomes with adjunctive systemic antibiotics may not be achievable in primary care.

There is high certainty evidence that systemic antibiotics can be beneficial in the treatment of periodontitis, However, the balance of risk and benefits on both an individual and collective basis is an important consideration in terms of antibiotic stewardship. There is widespread acceptance that inappropriate use of antibiotic therapy is linked to the increasing incidence of bacterial resistance. There are also numerous side effects associated with antibiotic therapy. Taking account of this, at both a patient and public health level, the BSP implementation of European S3 – level evidence-based treatment guidelines for stage I-III periodontitis in UK clinical practice (BSP-S3)⁶ guideline does not recommend the routine use of systemic antibiotics as an adjunct to subgingival instrumentation in patients with periodontitis. Similarly, this guidance includes a strong recommendation against the routine use of this intervention.

The BSP-S3 guideline notes that the adjunctive use of specific systemic antibiotics may be considered for specific patient categories (e.g. periodontitis Grade C in younger adults where a high rate of progression is documented) but suggests that adoption of this management option should be determined by a specialist or special interest periodontal practitioners.

Further details on the development of the recommendations in this guidance can be found in Methodology.