Antibiotics in the

The basis of a decision to use or not to use antibiotics

is essentially a balancing of those factors that tend to
Practice of Periodontics
require their use against those factors that tend to ob-
viate the need for them.
ANTIBIOTICS ARE NOT innocuous drugs. Their use should
be justified on the basis of a clearly established need
and should not be substituted for adequate local treat-
ment. The purpose of this paper is to review the funda-
mental considerations that form the basis for the ad-
ministration of antibiotics in the practice of periodon-
tics. Indications for therapeutic and prophylactic use
will be discussed separately.
Therapeutic indications for the use of antibiotics pre-
suppose an existing infection. The decision to use anti-
biotics therapeutically must be based on a consideration
of both the nature of the infection and the general
health of the patient. The following guidelines apply:
Certain special considerations should be discussed
relative to acute necrotizing ulcerative gingivitis, acute
(primary) herpetic gingivostomatitis, and recurrent aph-
thous stomatitis.
Acute Necrotizing Ulcerative Gingivitis
Acute necrotizing ulcerative girlgivitis (ANUG) is
believed to have a relatively specific bacterial compo-
nent and should be considered within the therapeutic
category. However, it is well established that in ANUG
all local irritants must be removed and that antibiotic
therapy is adjunctive treatment required only in special
cases.
What are the special cases? According to Glickman,l
"Antibiotics are administered systemically in patients
with toxic systemic complications or local adenopathy."
Prichard2 states that antibiotics should be prescribed for
ANUG if adequate local treatment cannot be provided
1. It is obvious that severe, acute, rapidly spreading
immediately. He further states that the acute symptoms
infections should be treated with antibiotics. The less
will be suppressed by antibiotic therapy but will recur
severe, localized infections where drainage can be estab-
unless adequate local therapy follows. Discussing the
lished will, in most cases, be resolved without the use of
use of antibiotics in ANUG, Goldman and CohenS say,
antibiotics.
"A case can be made for their use in acute fulminating
2. Evidences of systemic involvement, such as an
cases in conjunction with local therapy, but the adminis-
elevated temperature, general malaise, and lymphaden-
tration must be carried out with caution and close Super-
opathy, frequently indicate a need for antibiotics.
vision."
3. Infections in patients with certain systemic condi-
tions that predispose to the spread of infection generally
requite antibiotic therapy. Examples of such systemic
conditions are ( a) uncontrolled diabetes, (b) leukemia,
(c) agranulocytosis, (d) aplastic anemia, (e) Addison's
disease, (f) depressed natural defense mechanisms as a
result of therapy with adrenal steroids and immunosup-
pressive and cytotoxic drugs, (g) history of rheumatic
or congenital heart disease, and (h) debilitation by age
or disease.
4. Infections involving the region of the upper lip
and nose can be serious because of venous drainage into
the cavernous sinus. Antibiotics may be advantageous
for combating infections in this region that would other-
wise not require antibiotic therapy.
In general, antibiotics should not be used routinely
in the treatment of ANUG. They are seldom necessary,
and their indiscriminate use is a highly undesirable
practice. Although antibiotics will suppress the acute
symptoms of ANUG, they are strictly adjunctive to lo-
cal treatment and are indicated only in severe cases with
systemic involvement. As with other infections, the pa-
tient's general health should be considered in determin-
ing a need for these drugs. Some further justification
may exist for the use of antibiotics in cases of ANUG
that are tenaciously resistant to local treatment." How-
ever, in these instances one must determine the reason
for the resistance to local treatment rather than insti-
tute antibiotic therapy as a substitute for complete
evaluation of the patient.
Penicillin, erythromycin, and the tetracyclines are ef-
Commander, DC, USN; Head. Research and Sciences Depart-
fective against ANUG. ~ l ~ h ~ ~ ~ h specific studies have
ment, Naval Dental School, National Naval Medical Center,
Bethesda, Md.
not been reported, it is likely that lincomycin and clinda-
The opinions or assertions contained herein are the private
mycin would also be useful. There is some recent evi-
ones of the writer and are not t o be construed as official or as
reflecting the views of the Navy Department or the naval service
dence that the antitrichromonal drug metronidazole may
at large.
also be effective." 6
Volume 42
Number 9
Antibiotics in Periodontics 585
TABLE 1
Suggested Adult Dosage Schedules for Prevention of Bacterial
Endocarditis (Adapted from American Heart Association
Statementl6) :'
PARENTERAL SCHEDULE (Preferred)
Day of Procedure (1 to 2 hours before procedure)
600,000 units procaine penicillin G (IM) and
600,000 units K penicillin G (IM)
For 2 Days After Procedure
600,000 units procaine penicillin G (IM) daily
ORAL SCHEDULE
Day o f and 2 Days After Procedure
Penicillin V or phenethicillin (250 mg every 6 hours) or
K penicillin G (300 mg every 6 hours)
also: an extra dose 1 hour before procedure
PENICILLIN ALLERGY
Day of and 2 Days Af t er Procedure
Erythromycin (250 mg every 6 hours)
' The American Heart Association and the American Dental
Association are currently considering changes to these recom-
mendations. Any changes that evolve should be promulgated in
late 1971.
It is not particularly surprising that the topical use of
vancomycin has been demonstrated to be effective
against ANUG.'. However, the fact that an antibiotic
is applied locally rather than systemically does not ne-
gate the previously stated objections to routine antibiotic
therapy in ANUG. In actuality, the topical application of
any parenterally useful drug is open to some question.
This is particularly true if the application is made rou-
tinely. Although the parenteral use of vancomycin
against serious staphylococcic infection has declined
since the advent of the penicillinase-resistant penicillins,
'
its widespread use against a rather simply treated condi-
tion such as ANUG may, through the development of
patient allergies and bacterial resistance, complicate the
treatment of some life-threatening infections. Over the
past several years, staphylococci have appeared that are
not susceptible to the penicillinase-resistant penicillins.
Fosterg stated in a 1969 issue of Medical Clinics of
North America, "Vancomycin is our most reliable single
agent against penicillin-resistant staphylococci, and its
value happily extends over much of the rest of the gram-
positive spectrum as does that of penicillin." Although
this may not represent a universally accepted view, it
does indicate that there are physicians who rely heavily
on this drug for certain severe infections. It would ap-
pear that the topical use of vancomycin might be justi-
fied in severe cases of ANUG or where the patient is
physically or mentally incapable of adequate coopera-
tion. At any rate, one should not apply vancomycin in
the routine treatment of ANUG.
Acute(Primary) Herpetic Gingivostomatitis
Since this infection is of viral etiology, antibiotic ther-
apy is helpful only in case of secondary infection. How-
ever, some patients are said to experience relief follow-
ing the use of tetracyclines.10 It is possible that some
"herpetic" lesions that respond to tetracyclines are ac-
tually recurrent aphthae or are secondarily infected.
Since acute herpetic gingivostomatitis may be associated
with upper respiratory infection, pneumonia, and other
systemic disease, examination by a physician is fre-
quently indicated. Many pediatricians treat severe cases
of herpetic gingivostornatitis prophylactically with anti-
biotics. The value of this precautionary treatment is not
established.
Recurrent Aphthous Stomatitis
It appears that a pleomorphic streptococcus may be
involved in the pathogenesis of recurrent aphthous sto-
matitis.ll-I* Graykowski et all1 reported that 69% of
the cases of recurrent aphthae studied responded to
tetracycline in a 250 mg/5 ml suspension given four
times daily for five to seven days. The suspension (5 ml
for adults) was held in the mouth for two minutes and
then swallowed. Any advantage of holding the suspen-
sion in the mouth for two minutes as opposed to the use
of tetracycline capsules or tablets is not established.
Tetracycline mouthwashes have also been reported to be
helpful against recurrent aphthous stomatitis by Gug-
genheimer and coworkers.]"
The prophylactic use of antibiotics anticipates the
likelihood of a new infection or the exacerbation of an
existing infection. A definitive indication for prophy-
lactic antibiotic coverage is present when a patient with
rheumatic or congenital heart disease is to undergo pro-
cedures that may precipitate a bacteremia. The Amer-
ican Heart Association has published a statement16 dis-
cussing the rationale for prophylactic coverage and
giving suggested dosage schedules (see Table 1) . It has
been suggested that antibiotic prophylaxis for patients
with heart prostheses should be much more extensive
than that which is considered adequate in patients with
rheumatic or congenital heart disease. A regimen that
has been employed at the National Heart Institute, Na-
tional Institutes of Health, has been reported.li Unfor-
tunately, most prophylactic indications are not so defi-
nite as these instances in which prophylaxis against sub-
acute bacterial endocarditis is required.
Some practitioners routinely provide antibiotic cover-
age for surgical patients on the premise that such pro-
phylaxis may avert postsurgical infection, enhance the
surgical results, and/or reduce postoperative discomfort.
Prevention of Postsurgical Infections
The use of antibiotics to prevent postsurgical infec-
tions has been challenged in medical practice. In 1966,
Karl and co-workersls reported a double-blind study of
586 Holroyd
J. Periodont.
September, 1971
150 surgical cases. They found a wound infection rate
of 18.5 % in those patients receiving antibiotics prophy-
lactically and 12.9% in the control group. In an assess-
ment of the prophylactic value of antibiotics in over
1,000 cases of general surgery, Johnstone1g observed
that ". . . prophylactic antibiotics not only failed to pre-
vent but also were in fact associated with an increase in
the infections of all types." The failure of prophylactic
antibiotic therapy to prevent postoperative infections is
well documented in the medical l i t er at ~r e. l ~- ~l Unfortu-
nately, similar dental evaluations are not available. One
must view with some concern the philosophy of rou-
tinely using antibiotics prophylactically in an attempt
to prevent postsurgical infections. Unquestionably, con-
cern for aseptic and atraumatic operating techniques is
of great importance.
Most patients who undergo periodontal surgery are
not going to develop a postoperative infection. Infec-
tions that do evolve might have been prevented by pro-
phylactic antibiotics if the invading organism was sus-
ceptible to the pasticular drug selected. It is apparent
from medical studies that some individuals who would
not have developed a postoperative infection may do
so if prophylactic antibiotics are used. The mechanism
of this may be related to alterations in the normal flora
which were induced by the antibiotic. Thus, in the final
analysis, one must balance the infections he prevents
with antibiotics against the infections he causes with anti-
biotics. If the medical literature on this subject accu-
rately reflects the situation in periodontal surgery, the
gains and losses in using antibiotics to prevent postsur-
gical infection are approximately equal. One's capacity
to gain more than he loses from using antibiotics to
prevent postsurgical infections is likely to be propor-
tional to his ability to predict the likelihood of a post-
operative infection in a particular case.
Enhancement of Surgical Results
Many practitioners use antibiotics routinely in bone
grafting procedures and when attempting to establish a
new attachment at a more coronal level. Although some
logic underlies such use, no significant research evidence
is available to indicate that antibiotics are necessary or
even helpful in obtaining the desired result.
In regard to healing generally, Stah132 reported that
rats receiving antibiotics showed more distinctive crestal
bone repair than did control rats in the early stages of
healing; however, ". . . the beneficial potential of these
drugs did not, under our experimental conditions, influ-
ence ultimate repair levels.'' In further studies with rats,
Stahl concluded that antibiotics enhanced connective tis-
sue reattachment,33 but he later reported that the bene-
fits noted had been the result of an effect of the anti-
biotic on pulpal repair rather than on the reattachment
potential of the soft tissue." In 1964, StahlY5 reported
that an experimental group of protein-deprived rats,
treated with antibiotics following gingival wounds, ex-
hibited more crestal osteogenesis than did a control
group. Because of the superimposition of a nutritional
deficiency, it is difficult to apply these results to the
present discussion of the clinical use of antibiotics. Also
in 1964, Schafer and his associates36 reported a favor-
able effect of antibiotics on healing following osseous
contouring in dogs.
In 1969, Stahl and c o- w~r ke r s ~~ reported the results
of a clinical study of the effects of antibiotics in 48 pa-
tients. All subjects received l Gm erythromycin stearate
per day (four divided doses) for four days following a
gingivectomy. Histologic analyses were made of the tis-
sues removed by gingivectomy and biopsies taken at 1,
2, 3, 4, 6, and 8 weeks after surgery.
They showed differences in the inflammatory state of
the tissues before and after gingivectomy. No compari-
son was discussed between the inflammatory state of
the postoperative biopsies taken from antibiotic treated
and non-antibiotic treated patients. Since all subjects in
this report received antibiotics, such a control compari-
son would have had to be drawn from other studies.
They further reported that the epithelialization of all
wounds appeared to be complete within the first week
after surgery. They contrasted this with epithelializa-
tion obtained in only 61 % to 78% of biopsy specimens
in earlier studies.38~ 39
Although the foregoing studies have made significant
contributions to the understanding of the effect of anti-
biotics on wound healing, they cannot be considered
adequate justification for the use of antibiotics to en-
hance the results of periodontal surgery. In this area,
the use of antibiotics continues to be highly speculative.
Reduction of Postoperative Discomfort
The reduction of postoperative discomfort is inti-
mately related to the rate of wound healing. As previ-
ously stated, antibiotic-wound healing studies are in-
conclusive. However, AriaudodO has published a report
of a double-blind study which found that lincomycin
(500 mg, q.6 h., two days before and four days after
surgery) reduced the incidence of malaise, edema, ne-
crosis and pain following periodontal surgery. This pa-
per raises most interesting possibilities, and further
studies in this area are indicated.
Periodontal Dressings
Antibiotics have been used in periodontal dressings.
In 1956, Fraleigh4I reported that he had observed cer-
tain advantages in a pack containing a tetracycline, but
he also found undesirable tissue reactions. In 1958,
Volume 42
Number 9
Antibiotics in Periodontics 587
Baer, et al49eported favorably on a dressing containing
bacitracin, which was said to afford maximum patient
-
comfort with cleaner, less stained teeth and with less
associated debris. They observed no allergic or fungal
complications. In 1960, Baer and his co-workers43 de-
scribed a hydrogenated fat-bacitracin pack, and again
the report was favorable. In two years of study, they
observed only one case of infection with Candida al-
bicans. Later, R ~ m a n o w ~ ~ studied the relationship be-
tween moniliasis and periodontal packs containing anti-
biotics. With tetracycline and oxytetracycline packs, he
observed both stomatitis and moniliasis. With bacitracin
packs, he found neither stomatitis nor any signs or
symptoms of moniliasis though he noted an increase in
the presence of C. albicans.
From the foregoing studies, it would seem that packs
containing tetracyclines are undesirable, whereas baci-
tracin packs appear to offer certain advantages and to
have no clinically significant disadvantages. At this
point it should again be noted that the topical use of any
parenterally useful antibiotic is subject to question.
Bacitracin is primarily a topical antibiotic and is there-
fore relatively free from this disadvantage.
Bacterial Plaque and Gingivitis
With a relationship between bacteria and periodontal
disease well established, it logically followed that efforts
would be made to observe the effects of antibiotics on
dental plaque, gingivitis and periodontitis. The addition
of penicillin4j. 46 and chl~rtetracycline~~. 4g to the diet of
rodents has been shown to reduce plaque formation.
Dietary penicillin, erythromycin, polymyxin B, and oxy-
tetracycline have been shown to be effective in the pre-
vention or treatment of the periodontal syndrome in the
rice rat.", Topical vancomycin has been reported to
reduce plaque51 and to provide clinical improvement in
gingivitis and various oral lesions in humans.52 A study
of children on extended systemic penicillin prophylaxis
did not reveal a significantly beneficial effect on gingival
scores;53 however, systemic spiramycin has been shown
to have beneficial effects on periodontal disease in hu-
mans.54 Lobene and co-workers" have reported that the
use of an erythromycin liquid suspension (250 mg q. 6
h.) for seven days reduced plaque formation by 35%
and was particularly impressive in decreasing or elim-
inating spirochetes for 5 to 18 weeks after administra-
tion.
In a recent article, Bowers and co-workers56 stated
that there is insufficient evidence at present to justify
the general use of any antibiotic as a plaque control
agent in the prevention and treatment of gingivitis and
periodontitis. The literature indicates that although the
use of antibiotics in attempts to control plaque and to
improve nonspecific gingivitis and periodontitis appears
to be a promising line of research, it is too early for
antibiotics to be generally used for these purposes. How-
ever, this line of research represents what may ultimately
be the most effective approach to the prevention of
periodontal disease; that is, plaque control by pharma-
cologic means.
In certain oral infections, such as ANUG and recur-
rent aphthous stomatitis, the etiologic agents are rela-
tively predictable on the basis of the diagnosis. As pre-
viously stated, penicillin, erythromycin, and the tetra-
cyclines are all effective against ANUG, and the tetra-
cyclines appear to be effective to some degree against
recurrent aphthous stomatitis. In these cases, the anti-
biotic is selected on the basis of the diagnosis.
Streptococcus viridans is the organism of primary
concern in subacute bacterial endocarditis. Therefore, in
preventing subacute bacterial endocarditis, one is pri-
marily concerned with S. viridans. Consequently, peni-
cillin is the antibiotic of choice since it is highly effective
against that organism. In this case, the drug is selected
on the basis of what is known about the infection. Un-
fortunately, periodontists must also treat many infec-
tions in which the etiologic agents cannot be accurately
predicted on the basis of the symptomatology. Ideally,
in such cases, material from the infection should be cul-
tured and sensitivity tests carried out to determine what
antibiotic is effective against the specific etiologic agent.
For practical reasons, however, periodontal infections
are usually treated without the benefit of sensitivity
tests. Most bacteria that are causative agents in perio-
dontal abscesses and postoperative infections are within
the antibacterial spectra of penicillin, erythromycin, the
tetracyclines, lincomycin and clindamycin. In all fair-
ness, it should be said that sensitivity tests will show that
any of these antibiotics will be effective on the culture
plate against most bacteria sampled from periodontal in-
fections. Thus, the periodontist is justified in starting
treatment with one of these drugs before obtaining the
results of sensitivity tests for an infection that requires an
antibiotic. The primary advantage of sensitivity tests is
that they will let the clinician know whether he is dealing
with a bacterium that is insensitive to the most com-
monly effective drugs.
When an antibiotic is selected without the benefit of
sensitivity tests, the choice is essentially between peni-
cillin, erythromycin, the tetracyclines, and possibly lin-
comycin and clindamycin. The selection of a specific
antibiotic should be based on a knowledge of the phar-
macology of the individual drugs. Unquestionably, peni-
cillin is the drug of choice when a potent bactericidal
agent is required. However, the periodontist must always
remember that penicillin is the most allergenic drug in
current use and should never be used arbitrarily; it
should be selected only on the basis of an established
588 Holroyd
J. Periodont.
September, 1971
need for penicillin. When such need exists but the use of
penicillin is contraindicated because of patient allergy,
erythromycin and sodium cephalothin are usually good
substitutes. The principal disadvantage of sodium ceph-
alothin in dentistry is the fact that only parenteral forms
are available. However, this antibiotic may be of great
importance in serious infections caused by organisms
that are not affected by penicillin. Clindamycin may also
be effective in this regard. Where bacteriostatic action
will suffice, the tetracyclines should be effective.
How frequently a particular clinician will use peni-
cillin instead of a bacteriostatic drug depends on his
philosophy regarding the need for any antibiotic. The
clinician who accepts a very narrow range of indications
for antibiotics will usually need a potent bactericidal
agent if he feels that he needs any antibiotic. This in-
dividual should use penicillin in most cases. Although
he would be using penicillin almost exclusively, he
would not necessarily be using it indiscriminately. On
the other hand, some clinicians accept a very broad
range of indications for antibiotics and use them in
many situations where bacteriostatic drugs would be
adequate. If these individuals use penicillin almost ex-
clusively, they will be using it indiscriminately.
I n this limited discussion of the antibiotic of choice,
no attempt has been made t o resolve the question of
which drug t o use but only to stress the fact that an
antibiotic should not be chosen arbitrarily but should
be selected to meet the needs of the case. This selection
must be based upon a knowledge of (1) the state of
the patient's general health, (2) the nature of the spe-
cific infection involved, and ( 3) the pharmacology of
the drugs available.
SUMMARY
The use of antibiotics involves certain disadvantages
as well as advantages. Consequently, the decision t o use
these drugs should be based on an established need.
Points t o be considered in establishing the need and
selecting the proper drug have been presented.
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Volume 42
Number 9
Antibiotics in Periodontics 589
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Abstracts
MESIAL DRIFT OF TEETH IN ADULT MONKEYS (MACACA IRUS)
WHEN FORCES FROM THE CHEEKS AND TONGUE
HAD BEEN ELIMINATED
Moss. J. P. and Picton, D. C. A.
Arch. Oral Biol. 15:979, October, 1970
Cheek teeth on one side of the mouth were covered by an
acrylic dome to eliminate the effect of muscles and direct occlu-
sal forces. The same teeth on the opposite side of the mouth
were used as controls. The opposing teeth on both sides were
extracted to eliminate the influence of occlusal forces. Tooth
contacts were removed with a diamond disc allowing for move-
ment of the teeth. From 6 to 17 weeks it was observed that the
controls and the experimental sides both drifted mesially at
about the same rate, which led to a conclusion that the cheeks
and tongue did not play a significant part in mesial drift in these
animals. University College Hospital Dental Sclzool, Londorz,
W.C. I , England.
Armstrong, W. G.
Arch. Oral Biol. 15: 1001, October, 1970
Samples of whole human saliva were stirred with synthetic
hydroxyapatite preparations, and then submitted for disc elec-
trophoresis. It was found that high proline, high glutamic acid
and high glycine levels made up about one-half of the total
amino acid residues. Significant (0.5 percent) quantities of hex-
osamine were present, implying a glycoprotein nature for the
components. Parotid saliva samples that were taken showed
basically the same results. I n addition there was significantly less
aspartic acid, threonine and isoleucine. Departnzent of Biochem-
ist,-)., Tlze Royul Derztal Hospital, School of Dental Surgery, 32
Leicestrr Square, LolZdon, W.C. 2, England.