|
 |
| ORIGINAL ARTICLE |
|
| Year : 2023 | Volume
: 22
| Issue : 3 | Page : 293-299 |
|
|
Systemic antibiotic prescribing patterns of dentists in Morocco: A questionnaire study
Jamila Kissa, Sihame Chemlali, Amina Gharibi
Department of Periodontology, Faculty of Dentistry, Hassan II University, Casablanca, Morocco
| Date of Submission | 24-Mar-2022 |
| Date of Acceptance | 28-Apr-2023 |
| Date of Web Publication | 4-Jul-2023 |
Correspondence Address:
Amina Gharibi
Department of Periodontology, Faculty of Dentistry, Hassan II University, Casablanca
Morocco
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/aam.aam_50_22
 Abstract | | |
Aim: The aim of this study was to describe the use patterns of antibiotics in periodontal therapy among Moroccan dentists. Materials and Methods: It was a cross-sectional study. An online survey among 2440 registered dentists was conducted in public, private, and semi-public sectors in Morocco. Within the interrogated dentists, 255 answer the online survey. Data analysis was done by the laboratory of biostatistics-epidemiology of the Faculty of Medicine of Casablanca. Results: The antibiotics were prescribed for different pathologies. 26.8% of dentists prescribed antibiotics for gingivitis, 91.5% in case of ulcero-necrotizing gingivitis, 92.7% for aggressive periodontitis, 77% to chronic periodontitis patients, and 97.6% in the presence of periodontal abscess. Dentists prescribed penicillin to 37.3% of cases presenting ulcero-necrotizing gingivitis and 62.3% of patients presenting periodontal abscess. Cyclins are prescribed at a rate of 60% to aggressive periodontitis patients. The association of penicillin + metronidazole is prescribed to 37.3% of ulcero-necrotizing gingivitis patients, 47% of patients presenting aggressive periodontitis, 42.5% of chronic periodontitis patients, and 65.5% of cases presenting periodontal abscess. Discussion: There are major discrepancies among dentists in antibiotic prescription patterns. Some dentists prescribe antibiotics to patients with gingivitis or patients undergoing noninvasive oral procedures such as air polishing and scaling which is worrisome. Dentists are prescribing antibiotics when local treatment would have sufficed. Dentists also commonly prescribed antibiotics as an adjunct to mechanical therapy for the treatment of periodontal disease. Conclusion: Systemic antibiotics are prescribed for different conditions according to variable protocols. The appropriateness of antibiotic prescription must be reassessed critically to improve antibiotic stewardship among dentists.
Résumé
Objectif: Le but de cette étude était de décrire les modèles d'utilisation des antibiotiques en thérapie parodontale chez les dentistes Marocains. Matériaux et méthodes: C'était une étude transversale. Une enquête en ligne entre 2440 dentistes enregistrées a été menée dans des secteurs public, privé et semi-publique au Maroc. Dans les dentistes interrogés, 255 répondent à l'enquête en ligne. L'analyse des données a été effectuée par le laboratoire de biostatistique - épidémiologie de la Faculté de médecine de Casablanca. Résultats: Les antibiotiques ont été prescrits pour différentes pathologies. 26,8% des dentistes ont prescrit des antibiotiques pour la gingivite, 91,5% en cas de gingivite ulcéro-nécrotante, 92,7% pour la parodontite agressive, 77% aux patients atteints de parodontite chronique et 97,6% en présence d'un abcès parodontal. Les dentistes ont prescrit la pénicilline à 37,3% des cas présentant une gingivite ulcérative 1A8Q7 et 62,3% des patients présentant un abcès parodontal. Les cyclins sont prescrits à un taux de 60% aux patients atteints de parodontite agressive. L'association de la pénicilline + métronidazole est prescrite à 37,3% des patients atteints de gingivite ulcératisants, 47% des patients présentant une parodontite agressive, 42,5% des patients atteints de parodontite chronique et 65,5% des cas présentant un abcès parodontal. Discussion: Il y a des écarts majeurs chez les dentistes dans les modèles de prescription antibiotiques. Certains dentistes prescrivent des antibiotiques aux patients atteints de gingivite ou de patients subissant des procédures orales non invasives telles que le polissage et l'échelle de l'air qui sont inquiétantes. Les dentistes prescrivent des antibiotiques lorsque le traitement local aurait suffi. Les dentistes ont également couramment prescrit les antibiotiques comme complément à la thérapie mécanique pour le traitement des maladies parodontales.
Mots-clés: Dentistes, parodontite, antimicrobiens systémiques
Keywords: Dentists, periodontitis, systemic antimicrobials
How to cite this article:
Kissa J, Chemlali S, Gharibi A. Systemic antibiotic prescribing patterns of dentists in Morocco: A questionnaire study. Ann Afr Med 2023;22:293-9 |
| Introduction | |  |
Antibiotics are important in the treatment and prevention of advanced health diseases. However, they must be prescribed in a good manner to reduce adverse effect drug reactions. Indeed, the incorrect use of antibiotics provokes the proliferation of opportunistic bacteria and promotes the overgrowth of antibiotic-resistant bacteria causing worse clinical outcomes.[1]
Prescribing guidelines and antimicrobial stewardship initiatives underline the need to minimize unnecessary prescription of antibiotics and the obligation to ensure that antibiotics are prescribed correctly, with the optimal spectrum of antimicrobial activity reducing the risk of bacterial drug resistance and the risk of adverse effects while enhancing effectiveness.[2]
Dental professionals should participate in an active way in antibiotic stewardship (AS) initiatives as dentists prescribe a significant proportion (7%–11%) of antibiotics.[3] Research in British Columbia, Canada, find that antibiotic prescriptions by dentists are increasing at an alarming way.[1] Indeed, good data from the National health service (NHS) in the UK find that dentists responded well to AS and have reduced their antibiotic prescriptions more than in other domains of primary care between 2010 and 2017.[2]
Clinicians must also explain to their patients the side effects of antibiotics like hypersensitivity reactions and opportunistic infections to justify the reservation of antibiotic treatment to the necessary situations.[4]
The infectious nature of periodontal disease justifies the use of antibiotics in the periodontal treatment and the limits of conventional mechanical therapy.[3],[5] Effectively, it is known that mechanical debridement is the effective treatment of periodontal disease that disorganizes the biofilm. However, it is ineffective against certain periodontal pathogens such as Aggregatibacter actinomycetemcomitans, Porphyromonas gingivalis, Prevotella intermedia, and Tannerella forsythia and fails to eliminate periodontal pathogens within subepithelial gingival tissue, crevicular epithelium, or furcal area. Antibiotics can be used as adjunctive treatment to periodontal debridement because they eliminate pathogenic bacteria inaccessible to mechanical treatment.[6]
A systematic review of Cochrane Library concluded that the adjunctive use of antibiotics to periodontal therapy (scaling and root planing) results in statistically significant clinical benefits (reduction in probing depth and clinical attachment level gain).[7] A systematic review by Haffajee et al. found a clinical benefit in terms of a gain in attachment level when systemic antibiotics were prescribed to supplement surgical periodontal therapy in deep pockets.[8] On the other hand, a review by Herrera et al. suggested that there are inadequate data as to whether supplementing surgical periodontal therapy with systemic antibiotics was beneficial.[9]
The aim of this study was to describe the use patterns of antibiotics in periodontal therapy among Moroccan dentists.
| Materials and Methods | | |
This work was a cross-sectional study. An online survey among 2440 registered dentists was conducted in public, private, and semi-public sectors in Morocco. Within the interrogated dentists, 255 answer the online survey.
The questionnaire was anonym and investigated:
- The periodontal practice among dentists
- Different situations of antibiotic prescription
- Duration of antibiotic intake
- The use of systemic antibiotics for a spectrum of common clinical periodontal/peri-implant conditions and procedures: These procedures included tooth scaling, root planing, flap surgery, crown lengthening, mucogingival surgery, implant placement, and periodontal regeneration. For each condition/procedure, the types of systemic antibiotics used, their frequency of prescription, and order of preference were investigated.
Data analysis
Data analysis was done by the laboratory of biostatistics-epidemiology of the Faculty of Medicine of Casablanca.
| Results | | |
From the 255 responders, 234 answer the question about the age. Hence, 46.6% of dentists have an age up to 35 years, 50.4% were between 35 and 49 years old, and 3% were aged more than 50 years.
Two hundred and fifty-five dentists have specified the area where they exercise. 1.2% of practitioners were in the rural zone and 98.8% of responders were exercising in the urban area.
Eighty-four percent of dentists did periodontal examination systematically, 99% realized tooth scaling, and 70% did root planing. Dentists also did periodontal surgical therapies in there dental clinics. So hence, 23% did flap surgeries, 21.5% did crown lengthening procedures and only 3.2% did gingival grafts and 2% realized surgical regeneration procedures.
Ninety-nine percent of respondents prescribed antibiotics to prevent infection, 44% prescribed antimicrobials to prevent inflammation, 35% did it to control pain, whereas 87% prescribed antibiotics to insure a good healing.
The antibiotics were prescribed for different pathologies. 26.8% of dentists prescribed antibiotics for gingivitis, 91.5% in case of ulcero-necrotizing gingivitis, 92.7% for aggressive periodontitis, 77% to chronic periodontitis patients, and 97.6% in the presence of periodontal abscess.
The frequency of antibiotic prescription according to periodontal procedure is reported in [Table 1]. 5.2% of practitioners prescribed antibiotics for air polishing, 39.6% for scaling, and 68.6% for root planing. | Table 1: Frequency of antibiotic prescription according to periodontal procedure
Click here to view |
Antibiotics were often used in association with surgical treatment. Hence, 83% of dentists did antibiotic prescription in 83% of cases for flap surgeries, 80.3% for crown lengthening, 92.6% during gingival graft procedures, 100% for regeneration therapy, and 94.1% when performing implant surgery.
The most frequently used antibiotics were penicillin, macrolide, cycline, imidazoles, and the association of metronidazole and amoxicillin [Table 2]. | Table 2: Antibiotic families prescribed in different periodontal conditions
Click here to view |
Dentists prescribed penicillin to 37.3% of cases presenting ulcero-necrotizing gingivitis and 62.3% of patients presenting periodontal abscess. Cyclins are prescribed at a rate of 60% to aggressive periodontitis patients. The association of penicillin + metronidazole is prescribed to 37.3% of ulcero-necrotizing gingivitis patients, 47% of patients presenting aggressive periodontitis, 42.5% of chronic periodontitis patients, and 65.5% of cases presenting periodontal abscess.
When considering antibiotic prescription related to surgical therapy, 70.1% of dentists prescribed antibiotics for 7 days at least, 26.9% for 8–15 days, and 3% for more than 15 days [Table 3]. 34.3% of dentists prescribed antibiotics before the intervention, 25.7% started the prescription the day of the intervention, and 40% did the prescription before and after the intervention. | Table 3: Mean duration of antibiotic prescription in different periodontal conditions
Click here to view |
| Discussion | | |
Despite the fact that systemic antibiotics are used in periodontal disease for the last decades, there are limited data about prescription patterns around the world.
Periodontal diseases are generally clinically diagnosed, often without microbiological sampling.[6] This study aimed to describe the self-reported practices of Moroccan dentists toward antibiotic use in periodontal therapy and assess the appropriateness of systemic antibiotic prescription for this indication.[3]
There are major discrepancies among dentists in antibiotic prescription patterns. Some dentists prescribe antibiotics to patients with gingivitis or undergoing noninvasive oral procedures such as air polishing and scaling which is worrisome.
Dentists are prescribing antibiotics when local treatment would have sufficed. Dentists also commonly prescribed antibiotics as an adjunct to mechanical therapy for the treatment of periodontal disease.
The use of systemic antibiotics is more common when realizing surgical interventions (such as implant placement surgery and mucogingival surgery) compared to treating periodontal conditions in the absence of surgical interventions (such as chronic periodontitis with nonsurgical debridement).
In fact, postoperative infection can be the nightmare of any clinician who is dealing with regenerative and reconstructive oral surgical procedures.[4] It is possible that some clinicians today use antibiotics as a type of insurance against adverse surgical outcomes, particularly when they relatively lack experience with dental implant placement.[10] Thus, many different pre- and postoperative antibiotic regimens have been proposed to prevent postoperative infection and indirect early implant loss.[4]
The use of postoperative antibiotics in implant surgery is a controversial situation in the literature due to heterogeneity and insufficient data in clinical studies. There is no conclusive report regarding its relationship with postoperative infection. Antibiotic use in healthy patients for the prophylaxis of surgical infection associated with dental implant placement does not appear to improve clinical outcomes. Practitioners should apply principles of antimicrobial stewardship and not use antibiotics as a routine measure in healthy patients.[10]
It has been stated in the last consensus report of European association of osseointegration (EAO) that in straightforward cases, antibiotic prophylaxis has not shown a beneficial effect, but in complex cases like procedures with grafting or immediate placement of implants and/or patients with systemic comorbidities which are causing disruption in the immune system, antibiotic prophylaxis has a beneficial effect.[4],[11]
According to the American Heart Association, amoxicillin is a safe and effective agent in patients, and is not associated with issues such as angioedema, urticaria, anaphylaxis, and type I hypersensitivity reactions to penicillin.[12]
Systematic reviews and meta-analyses showed that oral administration of 2 g or 3 g of preoperative amoxicillin 1 h before the operation may be helpful in preventing postoperative infection in peri-implant tissues.[4],[13],[14]
Despite the ready availability of amoxicillin with clavulanic acid, this agent is not used commonly despite it having a broader spectrum, due to its greater potential for adverse effects. Metronidazole was not used commonly, and it is suggested that this should be reserved for patients who have had previous periodontal problems. A final important consideration is that the clinician's experience may influence strongly the outcome of dental implant treatment.[10]
The rationale of using systemic antibiotics as part of a surgical protocol may be based on some reasons, such as:
- An adjunct in the treatment of specific disease profiles (“active” or refractory diseases, severe diseases, smokers, etc.), with periodontitis that could require a more “aggressive” treatment
- To prevent postsurgical complications, including infection
- In periodontal surgery aiming for periodontal regeneration
- Specific disease profiles.
The use of antibiotics may help to control initial inflammation, but it had no direct effects of clinical significance on bone regeneration or soft tissue attachment at 12 months.[15]
Careful patient selection, a meticulous surgical technique, and close postoperative plaque control are more important factors for the outcome of the therapy than the routine administration of antibiotics.[9]
In the study, dentists prescribed antibiotics for 91.5% in case of ulcero-necrotic gingivitis, 92.7% for aggressive periodontitis, 77% to chronic periodontitis patients, and 97.6% in the presence of periodontal abscess. The most frequently used antibiotics used by dentists were penicillin, macrolide, cycline, imidazoles, and the association of metronidazole and amoxicillin.
Antibiotic prescription is not justified for gingivitis patients. In case of ulcero-necrotizing gingivitis, the use of systemic antimicrobials may be considered when there is a systemic involvement (fever and/or malaise) or an unsatisfactory response to local treatment. Metronidazole 250 mg, every 8 h, may be an appropriate first choice of drug because it is active against strict anaerobes. Other systemic drugs have also been suggested, with acceptable results, including penicillin, tetracyclins, clindamycin, amoxicillin, or amoxicillin plus clavulanate.[16]
The commonly used antimicrobials in periodontal therapy are tetracycline, metronidazole, penicillin, macrolides, ciprofloxacin, and clindamycin. Metronidazole and amoxicillin are reported to be the most commonly used combination antibiotic regimen.[5]
For patients with periodontitis, study investigators have shown that the use of adjunctive antibiotics is effective only in certain clinical situations. For instance, patients who continue to loss attachment after conventional mechanical therapy and patients presenting aggressive or refractory forms of periodontitis,[9],[17] acute periodontal infections, or predisposing systemic health conditions (for example, diabetes) benefit from systemic antibiotics.[1],[17]
Furthermore, a recent systematic review of Cochrane Library concluded that the adjunctive use of antibiotic to periodontal therapy (scaling and root planing) results in statistically significant clinical benefits (reduction in probing depth and clinical attachment level gain). These clinical effects are maintained up to 12 months, but no evidence supports the persistence of these beneficial effects beyond 2 years.[7]
Haffajee et al., 2003, suggested in their meta-analysis that subjects with aggressive periodontitis exhibited a greater benefit from systemically administered agents than those who had chronic periodontitis, although significant benefit occurred in the second group.[8]
It was found that there were statistically significant improvements in attachment loss for tetracycline, metronidazole, and an effect of borderline statistical significance for the combination of amoxicillin plus metronidazole.
Oteo et al.[18] tested azithromycin in P. gingivalis-positive moderate chronic periodontitis. This systemic antimicrobial was chosen because of its convenient dosage, and the results reported significant benefits in both clinical and microbiological outcome variables after 6 months. Sampaio et al.[19] suggest no adjunctive benefit of azithromycin in the treatment of generalized chronic periodontitis.
Ornidazole, an antimicrobial drug similar to metronidazole, was tested in patients with chronic periodontitis, combined with scaling and root planing, and compared with scaling and root planing plus placebo. The results in the clinical variables at 6 months were significant in favor of the adjunctive use of the systemic antimicrobial.[20] Silva et al.[21] compared the adjunctive use of metronidazole alone with scaling and root planing versus the combination of metronidazole and amoxicillin, and with a placebo in patients with chronic periodontitis. Clinical and microbiological outcomes after 3 months revealed that the combination resulted in significantly better outcomes when compared with the placebo, whereas the comparisons with the metronidazole-alone group were not statistically significant.
Adjunctive use of metronidazole may be advantageous in the treatment of sites where effective root planing is precluded due to deep pockets or when anaerobic periodontal infections do not respond to conventional therapy.[22]
A systematic review of concomitant administration of systemic amoxicillin and metronidazole (amoxicillin + metronidazole) and scaling and root planing indicated the benefit of combination therapy compared to scaling and root planing alone.[23]
Mombelli et al. in 2015 found that in patients with moderate to advanced periodontitis, systemic amoxicillin plus metronidazole significantly enhanced the effects of full-mouth scaling and root planing.[24] In large, we found in this review that most practitioners prescribe antibiotics for 8 through 15 days, which is estimated as a long duration. There is little evidence in the literature to support the appropriate duration of treatment. However, therapeutic antibiotics typically are prescribed for 7 days or until 3-day symptom resolution. Long durations exceeding 7 through 10 days often are indicated in patients who are immunosuppressed or those with severe infections.[1]
If systemic antimicrobials are indicated in periodontal therapy, they should be adjunctive to mechanical debridement. Indirect evidence suggests that antibiotic intake should start the day of periodontal debridement completion. Debridement should be completed within a short time (preferably 1 week) and with an adequate quality, to optimize the results.[9],[25]
The appropriateness of antibiotics in dentistry and in periodontology must, in the light of recent scientific evidence, certainly be reassessed critically, especially in light of the additional long-term benefit and of all possible adverse drug reactions that may arise for the patient.
Indeed, the side effects of antibiotics applied in the treatment of periodontal diseases, the obtained results show that patients are at the risk of:[26]
- Allergy (5%)
- Nephritis (3%)
- Hematological problems (2%–2.5%)
- Gastrointestinal problems (5.5%)
- Disturbance in the nervous system (2%)
- Signs of allergy on the skin (5.5%)
- Problems with electrolytes displayed in lower percentages.
Proposed strategies to reduce the risk of bacterial antimicrobial resistance include prescribing two drugs with synergistic or complementary effect and administration of antibiotics at a high dose for a short period.[25]
The Faculty of General Dental Practice UK and the Faculty of Dental Surgery of the Royal College of Surgeons of England have published the third edition of Antimicrobial Prescribing in Dentistry – Good Practice Guidelines. The principles of this guideline are summarized in [Table 4].[27] | Table 4: The principles of antibiotic prescription guidelines of faculty of general dental practice and faculty of dental surgery
Click here to view |
The results of these analyses will help stakeholders understand the prescribing practices of dentists in Morocco and, ultimately, aid in the development of helpful antimicrobial stewardship efforts orienting prescription scheme. Finally, we propose the development of practical and definitive antibiotic prescribing guidelines with a clear description of indications and regimens to facilitate case selection and ease of use. Once in place, the uptake of and adherence to these clinical guidelines should be monitored continuously.[1]
| Conclusion | | |
Systemic antibiotics are prescribed for different conditions according to variable protocols. The appropriateness of antibiotic prescription must be reassessed critically to improve antibiotic stewardship among dentists.
Limits of the study
Among the limitations of this study, we can mention the low response rate; from 2440 questionnaires, we obtained just 255 responders. Hence, a rate of response was 10.5%. This rate can be explained by the lack of time of some practitioners, and/or the negative public perception on confidentiality or anonymity of online surveys. Despite this low rate, this study allowed a perception of antibiotic prescribing patterns of the dentists in Morocco.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Stein K, Farmer J, Singhal S, Marra F, Sutherland S, Quiñonez C. The use and misuse of antibiotics in dentistry: A scoping review. J Am Dent Assoc 2018;149:869-84.e5.  |
| 2. | Thornhill MH, Dayer MJ, Durkin MJ, Lockhart PB, Baddour LM. Oral antibiotic prescribing by NHS dentists in England 2010-2017. Br Dent J 2019;227:1044-50. |
| 3. | Agossa K, Sy K, Mainville T, Gosset M, Jeanne S, Grosgogeat B, et al. Antibiotic use in periodontal therapy among French dentists and factors which influence prescribing practices. Antibiotics (Basel) 2021;10:303. |
| 4. | Yalcin-Ülker GM, Cakir M, Meral DG. Antibiotic prescribing habits of the clinicians dealing with dental implant surgery in Turkey: A questionnaire study. Int J Implant Dent 2020;6:66. |
| 5. | Mahuli SA, Zorair AM, Jafer MA, Sultan A, Sarode G, Baeshen HA, et al. Antibiotics for periodontal infections: Biological and clinical perspectives. J Contemp Dent Pract 2020;21:372-6. |
| 6. | Ong A, Kim J, Loo S, Quaranta A, Rincon A JC. Prescribing trends of systemic antibiotics by periodontists in Australia. J Periodontol 2019;90:982-92. |
| 7. | Teughels W, Feres M, Oud V, Martín C, Matesanz P, Herrera D. Adjunctive effect of systemic antimicrobials in periodontitis therapy: A systematic review and meta-analysis. J Clin Periodontol 2020;47 Suppl 22:257-81. |
| 8. | Haffajee AD, Socransky SS, Gunsolley JC. Systemic anti-infective periodontal therapy. A systematic review. Ann Periodontol 2003;8:115-81. |
| 9. | Herrera D, Alonso B, León R, Roldán S, Sanz M. Antimicrobial therapy in periodontitis: The use of systemic antimicrobials against the subgingival biofilm. J Clin Periodontol 2008;35:45-66. |
| 10. | Park J, Tennant M, Walsh LJ, Kruger E. Is there a consensus on antibiotic usage for dental implant placement in healthy patients? Aust Dent J 2018;63:25-33. |
| 11. | Klinge B, Flemming T, Cosyn J, De Bruyn H, Eisner BM, Hultin M, et al. The patient undergoing implant therapy. Summary and consensus statements. The 4 th EAO consensus conference 2015. Clin Oral Implants Res 2015;26 Suppl 11:64-7. |
| 12. | Wilson W, Taubert KA, Gewitz M, Lockhart PB, Baddour LM, Levison M, et al. Prevention of infective endocarditis: Guidelines from the American Heart Association: A guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group. Circulation 2007;116:1736-54. |
| 13. | Romandini M, De Tullio I, Congedi F, Kalemaj Z, D'Ambrosio M, Laforí A, et al. Antibiotic prophylaxis at dental implant placement: Which is the best protocol? A systematic review and network meta-analysis. J Clin Periodontol 2019;46:382-95. |
| 14. | Esposito M, Grusovin MG, Worthington HV. Interventions for replacing missing teeth: Antibiotics at dental implant placement to prevent complications. Cochrane Database Syst Rev 2013;7:CD004152. |
| 15. | Demolon IA, Persson GR, Moncla BJ, Johnson RH, Ammons WF. Effects of antibiotic treatment on clinical conditions and bacterial growth with guided tissue regeneration. J Periodontol 1993;64:609-16. |
| 16. | Malek R, Gharibi A, Khlil N, Kissa J. Necrotizing ulcerative gingivitis. Contemp Clin Dent 2017;8:496-500. [ PUBMED] [Full text] |
| 17. | Herrera D, Sanz M, Jepsen S, Needleman I, Roldán S. A systematic review on the effect of systemic antimicrobials as an adjunct to scaling and root planing in periodontitis patients. J Clin Periodontol 2002;29 Suppl 3:136-59. |
| 18. | Oteo A, Herrera D, Figuero E, O'Connor A, González I, Sanz M. Azithromycin as an adjunct to scaling and root planing in the treatment of Porphyromonas gingivalis-associated periodontitis: A pilot study. J Clin Periodontol 2010;37:1005-15. |
| 19. | Sampaio E, Rocha M, Figueiredo LC, Faveri M, Duarte PM, Gomes Lira EA, et al. Clinical and microbiological effects of azithromycin in the treatment of generalized chronic periodontitis: A randomized placebo-controlled clinical trial. J Clin Periodontol 2011;38:838-46. |
| 20. | Pradeep AR, Kalra N, Naik SB. Systemic ornidazole as an adjunct to non surgical periodontal therapy in the treatment of chronic periodontitis: A randomized, double blinded placebo controlled clinical trial. J Periodontol 2012. [Epub ahead of print]. |
| 21. | Silva MP, Feres M, Sirotto TA, Soares GM, Mendes JA, Faveri M, et al. Clinical and microbiological benefits of metronidazole alone or with amoxicillin as adjuncts in the treatment of chronic periodontitis: A randomized placebo-controlled clinical trial. J Clin Periodontol 2011;38:828-37. |
| 22. | Greenstein G. The role of metronidazole in the treatment of periodontal diseases. J Periodontol 1993;64:1-15. |
| 23. | Zandbergen D, Slot DE, Niederman R, Van der Weijden FA. The concomitant administration of systemic amoxicillin and metronidazole compared to scaling and root planing alone in treating periodontitis: =a systematic review=. BMC Oral Health 2016;16:27. |
| 24. | Mombelli A, Almaghlouth A, Cionca N, Courvoisier DS, Giannopoulou C. Differential benefits of amoxicillin-metronidazole in different phases of periodontal therapy in a randomized controlled crossover clinical trial. J Periodontol 2015;86:367-75. |
| 25. | Heitz-Mayfield LJ. Systemic antibiotics in periodontal therapy. Aust Dent J 2009;54 Suppl 1:S96-101. |
| 26. | Heta S, Robo I. The side effects of the most commonly used group of antibiotics in periodontal treatments. Med Sci (Basel) 2018;6:6. |
| 27. | Nikolaus O, Palmer BDS MFGDP (UK) PhD RCSEng FFGDP (UK) Antimicrobial Prescribing in Dentistry. Good Practice Guidelines. 3 rd Edition. London, UK: Faculty of General Dental Practice (UK) and Faculty of Dental Surgery; 2020. |
[Table 1], [Table 2], [Table 3], [Table 4]
|
