Value of antibiotic prophylaxis in periodontal surgery

Patient-reported outcome measures after periodontal surgery

OBJECTIVES

The present study aimed to explore the impact of different periodontal surgical treatments on the quality of life and postoperative morbidity.

MATERIALS AND METHODS

The present study is a single-center, prospective, observational cohort trial. One hundred fifty-five patients, referred to the Periodontal Department of Bologna University who needed periodontal surgical treatment, were recruited. The self-reported perception of the postoperative course was assessed using the following anonymous questionnaires: Italian oral health impact profile (I-OHIP-14), visual analog scale (VAS) to evaluate the intensity of the pain, and 5-point Likert scale.

RESULTS

Patients reported a mean OHIP-14 total score of 9.87±8.5 (range 0-42), significantly influenced by the female sex, flap extension, and periodontal dressing. A mean VAS score of 2.96±2.39 (range 0-9) was calculated, and was found to be influenced by the presence of vertical releasing incisions and palatal flap extension. Of the 155 subjects, 40 (25.8%) patients reported bleeding as a post-surgical complication, 96 (61.9%) swelling, 105 (67.7%) eating discomfort, and 44 (28.4%) reported speech discomfort.

CONCLUSIONS

Within the limitations of the nature of the present study, periodontal surgical procedures have a low impact on patients' quality of life evaluated through the OHIP-14 and VAS pain questionnaires.

CLINICAL RELEVANCE

Periodontal surgical procedures are safe procedures, with a limited duration of postoperative discomfort as well as the incidence of complications.

Antibiotic prescribing practices in periodontal surgeries with and without bone grafting

BACKGROUND

The prevention of postoperative infection is often the basis for antibiotic prescription; however, the risks of unwarranted antibiotics and lack of guidelines for procedures involving bone grafts creates additional difficulty in decision making for practitioners. This study aims to evaluate practices in antibiotics prescribed for periodontal surgeries with and without bone grafting and acceptability of guidelines.

METHODS

An anonymous survey was distributed to periodontists via the California Society of Periodontists e-mail listserv. The survey questioned prescribing practices for periodontal procedures, prescribing rationale, demographic and dental practice information, and acceptability of guidelines. Results were analyzed using McNemar tests and logistic regression.

RESULTS

Practitioners were significantly less likely to prescribe antibiotics for traditional periodontal surgeries without bone grafting compared with socket preservation, guided tissue regeneration, guided bone regeneration, and sinus augmentation (P < 0.0001). Practitioners were significantly more likely to prescribe antibiotics with more complex bone grafting such as guided bone regeneration and sinus augmentation compared with socket preservation (P < 0.0001). The most common rationale for prescribing antibiotics with bone grafting was to decrease the chances of developing an infection. Seventy-five percent of practitioners reported they would follow guidelines for antibiotic prescription if they were developed by the American Academy of Periodontology.

CONCLUSIONS

Practitioners are more likely to prescribe antibiotics with bone grafting and as complexity of the bone grafting procedure increases. Based on these results, the low incidence of infection in periodontal surgery cited in the literature, and willingness of practitioners to adopt guidelines, the establishment of evidence-based guidelines would be of benefit to the periodontal practicing community.

A review of the literature: antibiotic usage and its relevance to the infection in periodontal flaps

OBJECTIVE

This study aimed to investigate the systemic antibiotic usage in the perioperative period of periodontal flaps and its relevance to the infection after surgeries through reviewing the papers of the last decade.

MATERIALS AND METHODS

A search was conducted for the studies of randomized clinical trials between 2005 and 2014 that reported periodontal flaps in chronic periodontitis patients. Data were extracted and the rate of the systemic antibiotic use, the infection rate after surgeries and the number needed to treat (NNT) to prevent one infected case were calculated. The impact of antibiotic use and materials used in surgeries on the infection was evaluated.

RESULTS

Eighty-three trials were included. Antibiotics were used in 73.7% of the patients and 75.4% of the flaps. Infection occurred in only five flaps where enamel matrix proteins (EMD) or EMD + bone grafts were used in intrabony defects. Only 0.170% of the surgeries got infected in total. When all kinds of surgeries were included for analysis, the infection rate was 0.073% for the surgeries using antibiotics, which was lower than the infection rate 0.693% for the surgeries not using antibiotics (p < .05). The infection rate was very low in general. NNT was 203 when all the surgeries were included for analysis. Therefore, the difference of the infection rates between using antibiotics and not might lack clinical significance.

CONCLUSIONS

Considering the very low incidence of the infection and the disadvantages of the systemic antibiotic use, we suggest not using systemic antibiotics in the perioperative period of periodontal flaps to prevent infection.

Antibiotics in periodontal surgeries: A prospective randomised cross over clinical trial

AIMS AND OBJECTIVES

(1) To evaluate the need of antibiotics in periodontal surgeries in reducing postsurgical infections and explore if antibiotics have any key role in reducing or eliminating inflammatory complications. (2) To establish the incidence of postoperative infections in relation to type of surgery and determine those factors, which may affect infection rates.

MATERIALS AND METHODS

A prospective randomized double-blind cross over clinical study was carried out for a period of 1-year with predefined inclusion and exclusion criteria. All the patients included in the study for any periodontal surgery were randomly divided into three categories: Group A (prophylactic), Group B (therapeutic), and Group C (no antibiotics). Patients were followed up for 1-week after surgery on the day of suture removal and were evaluated for pain, swelling, fever, infection, delayed wound healing and any other significant findings. Appropriate statistical analysis was carried out to evaluate the objectives and P < 0.05 was considered as statistically significant.

RESULTS

No infection was reported in any of 90 sites. Patients reported less pain and postoperative discomfort when prophylactic antibiotics were given. However, there were no statistical significant differences between the three groups.

SUMMARY AND CONCLUSION

There was no postoperative infection reported in all the 90 sites operated in this study. The prevalence of postoperative infections following periodontal surgery is <1% and this low risk does not justify the routine use of systemic antimicrobials just to prevent infections. Use of prophylactic antibiotics may have role in prevention of inflammatory complication, but again not infection.

Dissemination of periodontal pathogens in the bloodstream after periodontal procedures: a systematic review

BACKGROUND

To date, there is no compilation of evidence-based information associating bacteremia and periodontal procedures. This systematic review aims to assess magnitude, duration, prevalence and nature of bacteremia caused by periodontal procedures.

STUDY DESIGN

Systematic Review.

TYPES OF STUDIES REVIEWED

MEDLINE, EMBASE and LILACS databases were searched in duplicate through August, 2013 without language restriction. Observational studies were included if blood samples were collected before, during or after periodontal procedures of patients with periodontitis. The methodological quality was assessed in duplicate using the modified Newcastle-Ottawa scale (NOS).

RESULTS

Search strategy identified 509 potentially eligible articles and nine were included. Only four studies demonstrated high methodological quality, whereas five were of medium or low methodological quality. The study characteristics were considered too heterogeneous to conduct a meta-analysis. Among 219 analyzed patients, 106 (49.4%) had positive bacteremia. More frequent bacteria were S. viridans, A. actinomycetemcomitans P. gingivalis, M. micros and species Streptococcus and Actinomyces, although identification methods of microbiologic assays were different among studies.

CLINICAL IMPLICATIONS

Although half of the patients presented positive bacteremia after periodontal procedures, accurate results regarding the magnitude, duration and nature of bacteremia could not be confidentially assessed.

Postoperative bacteremia in periodontal flap surgery, with and without prophylactic antibiotic administration: A comparative study

OBJECTIVES

Many a times in clinical periodontology, the decision whether to prescribe prophylactic antibiotics or not, is perplexing.The present study was conducted to compare the bacteremias induced after periodontal flap surgeries with and without prophylactic antibiotics.

MATERIALS AND METHODS

The occurrence of postoperative bacteremia following periodontal flap surgery was studied in 30 patients. On these patients, 30 quadrant wise flap surgeries were carried out without any preoperative prophylactic antibiotics and 30 surgeries carried out after prophylactic administration of amoxycillin preoperatively. A blood sample was taken from each patient at the time of maximum surgical trauma and was cultured for micro-organisms and antibiotic sensitivity.

RESULTS

18 out of 60 blood samples were positive for micro-organisms. There was a significant reduction in post operative bacteremia after amoxycillin prophylaxis (x(2) - 7.96 with P<0.01) as post operative bacteremia was found in 14 of the non medicated patients as compared to only 4 of the pre medicated patients. The micro-organisms encountered in the study are as follows:- 1) Staphylococcus albus coagulase negative, 2) Klebsiella, 3) Psedomonas aerugenosa, 4) Streptococcus viridans, 5) Alpha hemolytic streptococcus, 6) Neisseria catarrhalis

CONCLUSION

On the basis of the study, it is concluded that the incidence of postoperative bacteremia following periodontal flap surgery is not as high as previously reported. The clinical results show that Amoxicillin is highly effective in reducing postoperative bacteremia in periodontal flap surgery and thus in preventing the possible sequelae (Infective Endocarditis and other systemic maladies) in susceptible patients. However, cefotaxime and cephalexin may prove to be more effective in preventing the same.

Antimicrobial therapy in periodontitis: the use of systemic antimicrobials against the subgingival biofilm

OBJECTIVES

The aim was to answer three relevant questions: can systemic antimicrobials be efficacious if the biofilm is not disrupted? Can the type of debridement of the subgingival biofilm impact upon the clinical outcomes of the adjunctive antimicrobial therapy? Is the efficacy of the adjunctive systemic antimicrobial therapy dependent on the quality of the debridement of the subgingival biofilm and the sequence debridement-antibiotic usage?

MATERIAL AND METHODS

Relevant papers were searched, critically analysed and their data were extracted.

RESULTS

For the first question, studies assessing susceptibility of bacteria in biofilms, and clinical studies evaluating systemic antimicrobials as monotherapy, were reviewed. For the second question, clinical studies comparing systemic antimicrobials as adjuncts to non-surgical debridement or to periodontal surgery and clinical trials using systemic antibiotics with periodontal surgery were evaluated. For the third question, a previous systematic review was updated.

CONCLUSION

If systemic antimicrobials are indicated in periodontal therapy, they should be adjunctive to mechanical debridement. There is not enough evidence to support their use with periodontal surgery. Indirect evidence suggests that antibiotic intake should start on the day of debridement completion, debridement should be completed within a short time (preferably <1 week) and with an adequate quality, to optimize the results.

Post-Surgical Infections: Prevalence Associated With Various Periodontal Surgical Procedures

BACKGROUND

Of the various adverse outcomes that may be encountered following periodontal surgery, the risk of infection stands at the forefront of concern to the surgeon, since infection can lead to morbidity and poor healing outcomes. This paper describes a large-scale retrospective study of multiple surgical modalities in a diverse periodontal practice undertaken to explore the prevalence of clinical infections post-surgically and the relationship between diverse treatment variables and infection rates.

METHODS

A retrospective review of all available periodontal surgical records of patients treated in the Department of Periodontics at Wilford Hall Medical Center, San Antonio, Texas, was conducted. The sample comprised 395 patients and included 1,053 fully documented surgical procedures. Surgical techniques reviewed included osseous resective surgery, flap curettage, distal wedge procedures, gingivectomy, root resection, guided tissue regeneration, dental implant surgery, epithelialized free soft tissue autografts, subepithelial connective tissue autografts, coronally positioned flaps, sinus augmentations, and ridge preservation or augmentation procedures. Infection was defined as increasing and progressive swelling with the presence of suppuration. The impact of various treatment variables was examined including the use of bone grafts, membranes, soft tissue grafts, post-surgical chlorhexidine rinses, systemic antibiotics, and dressings. Results were analyzed using Fisher's exact test and Pearson's chi-square test.

RESULTS

Of the 1,053 surgical procedures evaluated in this study, there were a total of 22 infections for an overall prevalence of 2.09%. Patients who received antibiotics as part of the surgical protocol (pre- and/ or post-surgically) developed eight infections in 281 procedures (2.85%) compared to 14 infections in 772 procedures (1.81%) where antibiotics were not used. Procedures in which chlorhexidine was used during post-surgical care had a lower infection rate (17 infections in 900 procedures, 1.89%) compared to procedures after which chlorhexidine was not used as part of post-surgical care (five infections in 153 procedures, 3.27%). The use of a post-surgical dressing demonstrated a slightly higher rate of infection (eight infections in 300 procedures, 2.67%) than non-use of a dressing (14 infections in 753 procedures, 1.86%). Despite these trends, no statistically significant relationship was found between post-surgical infection and any of the treatment variables examined, including the use of perioperative antibiotics.

CONCLUSIONS

The results of this study confirm previous research demonstrating a low rate of postoperative infection following periodontal surgical procedures. Although perioperative antibiotics are commonly used when performing certain regenerative and implant surgical procedures, data from this and other studies suggest that there may be no benefit in using antibiotics for the sole purpose of preventing post-surgical infections. Further large-scale, controlled clinical studies are warranted to determine the role of perioperative antibiotics in the prevention of periodontal post-surgical infections.

Bacteremia following subgingival irrigation and scaling and root planing

The purpose of this study was to determine the incidence of bacteremia after a single professional subgingival irrigation with a 0.12% chlorhexidine gluconate mouthrinse (CHX) as well as after a subsequent scaling and root planing (S/RP) during the same visit. Thirty subjects each with at least 1 site that probed 4 mm or more and bled on probing were randomly assigned to the following groups: 1) irrigation with 0.12% CHX; 2) irrigation with sterile water; and 3) non-irrigated controls. To begin the study blood was drawn just before and 2 minutes after irrigation. Thirty minutes later, blood was drawn again just before and 2 minutes after S/RP at the same site. Specimens were cultured for anaerobic and aerobic microorganisms using standard cultural techniques. Eighteen blood cultures from 15 subjects yielded positive cultures resulting in 23 isolates. Gram-positive rods comprised 34.8% of the total isolates; Gram-positive cocci 34.8%, Gram-negative rods 21.7%, and Gram-negative cocci 8.7%. In the CHX group, bacteremia was detected in 5 subjects after irrigation and in 2 other subjects after S/RP. In the water group, bacteremia was detected in one subject after irrigation and in 4 subjects after S/RP. The control group had 3 bacteremias after S/RP. There was no significant difference between the incidence of bacteremia associated with irrigation by CHX or sterile water (P = 0.141). There was also no significant difference in the incidence of bacteremia after S/RP between the CHX and sterile water irrigation groups and in patients who did not receive irrigation (control group) (P = 0.88).(ABSTRACT TRUNCATED AT 250 WORDS)

Susceptibility of Gardnerella vaginalis to cephradine

The activity of cephradine and the influence of pH on its activity against 70 Gardnerella vaginalis strains were determined. Serial dilutions of cephradine (0.062 to 256 micrograms/ml) were incorporated into Dunkelberg agar, inoculated with a Steers replicator, incubated in 5% CO2 for 48 h, and examined. The minimal inhibitory concentrations for 90% of the isolates were 16 and 8.0 micrograms/ml at pH 7.0 to 6.0 and 5.5, respectively.

Antimicrobial susceptibilities of bacteria associated with periodontal disease

A total of 193 bacterial strains were tested for their susceptibilities to 14 antimicrobial agents. Penicillin G was active at 2 U/ml against 98% of the oral isolates. Other antibiotics with good activity were cefoperazone, moxalactam, Sch 29,482, and clindamycin. Metronidazole was active against more than 90% of the anaerobic bacteria and Capnocytophaga but was inactive against most other microaerophilic and facultative strains.