Question:
I need a little perspective. I have moderate periodontal disease, and
despite direct request for a course of antibiotic treatment, have had
surgery recommended twice . My rough, untrained opinion, is that if
there is a medical alternative, why not try it. Is there harm in using
the antibiotic in a search for non surgical intervention . I'm willing
to do the surgery, but not until I've exhausted other options
In my search for an alternative I came across a series of articles by
Loesche (*) on the use of antibiotic in the treatment of periodontal
disease. Is there a substantive critique that suggests Loesche is
incorrect?
Answer:
Loche is not incorrect--as far as he goes. There is a theoretical role
of antibiotics for treatment of active periodontal disease.
The problem is pretty complicated (and I've got a patient waiting).
There is a place for antibiotics. However, there is abundant evidence
collected over many years that while the bacterial flora can be altered
SHORT TERM, it is unlikely to do so long term, and probably unwise to try.
It is unwise because the antibiotics necessary to do the job would both
predispose to superinfection with non-sensitive microbes, and likely
contribute to antibacterial resistance and sensitization of the patient
(as well as many other potential side effects of long-term use of these
medications).
There have been attempts to overcome some of the downside of antibiotic
therapy, by using various antibiotics (mostly doxycycline) topically,
and systemic use of low-dose doxycycline. In the topical application,
the rationale is to develop high local concentrations of antibiotic
without the other risks of systemic use. In the case of low-dose
systemic use, the drug is in fact given in concentrations ineffective
for antibiotic effect; however, advantage is taken of their activity in
inhibiting collagenase--an enzyme implicated in the breakdown of
periodontal tissues.
Both treatments have been around for some years now. While there is a
general concensus I've heard among periodontists that these drugs have
their place, esp. in certain periodontal lesions that either do not
respond to surgery or where for a variety of reasons surgery is not
considered worthwhile, general results are underwhelming. They may be
an adjunct, but they're not going to replace surgery.
I cannot tell from this abstract. He does not here define (for
example) "advanced" periodontal disease criteria. Nor (for that matter)
does he define either the "need for surgery" nor the "need for
extraction". These are awfully subjective measures, as opposed to
pocket depth, mobilities, or incidence of periodontal abscess.
Use of the word "astonishing" in a clinical study may
be hazardous to your health!
I am not going to dispute this study. But you should know that
use of metronidazole (some pretty nasty stuff, btw) in periodontal
disease is a very, very old story. This is the first study I've seen
that calls it "astonishing".
Which for me begs the question--what in this study could possibly lead
to an "astonishing" result when all the previous clinical findings have
been, well, non-astonishing?
