Sir, recently, dental practitioners have noticed the significant changes in the newest version of the British National Formulary, regarding antibiotics protocol for dental conditions. According to the BNF recommendations1 the systemic treatment of severe cases of periodontitis, resistant to mechanical debridement, can be based on mono-drug therapy with the use of metronidazole (alternative: doxycycline), the bactericidal agent targeting the gram-negative strict anaerobes from the 'red' and 'orange' Socransky complexes.
Despite the high efficiacy of metronidazole against anaerobic bacteria, particularly P. gingivalis and Prevotella intermedia,2 alone it has a limited effect against periopathogen Aggregatibacter actinomycetemcomitans (reclassified Actinobacillus actinomycetemcomitans), which is a facultative rather than a strict anaerobe and it is considered as the main causative factor in aggressive periodontitis.3-5 Actinomyces, Streptococcus and Capnocytophaga are also reported to be minimally affected by metronidazole.6
Chronic periodontitis is caused by a mixed microbial infection making the selection of targeted antibiotic difficult to justify. No single antibiotic with a relatively narrow spectrum of antibacterial activity can be effective against all periopathogens. Periodontal infections are represented by a broad diversity of periopathogens, including anaerobic, microaerophilic, and aerobic bacteria, both Gram negative and Gram positive. Hence, it is recommended to use more than one antibiotic with different antibacterial spectra.
The combination of metronidazole-amoxicillin and metronidazole plus amoxicillin-clavulanate potassium seems to be the most effective antimicrobial therapy in the management of advanced periodontitis.2,7,8 Amoxicillin reveals broader spectrum decreasing counts of Gram negative anaerobes, including also Aggregatibacter. This provides an elimination of bacteria in aggressive periodontitis that had been treated unsuccessfully with mechanical debridement and other, single antibiotics.
References
British National Formulary. Table 1. Summary of antibacterial therapy for ear, nose, and oropharynx. https://www.medicinescomplete.com/mc/bnf/current/PHP3268-ear-nose-and-oropharynx.htm
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Dziedzic, A., Wojtyczka, R. Periodontology: Antibiotics protocol. Br Dent J 217, 660 (2014). https://doi.org/10.1038/sj.bdj.2014.1106
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DOI: https://doi.org/10.1038/sj.bdj.2014.1106
