Prescribing Trends of Systemic Antibiotics by Periodontists in Australia

Alex Ong* DMD; Junghyun Kim* DMD; Samuel Loo* DMD

Alessandro Quaranta† DDS(Hons), PhD; Julio C Rincon A* PhD

Corresponding Author:

Dr Julio C Rincon A

Oral Restorative and Rehabilitative Sciences

The University of Western Australia, 35 Stirling Highway, Nedlands, 6009, WA

Email: julio.rincon@uwa.edu.au, Ph: +61 8 6457 7664

Word Count: 3882; Figures: 5; Tables: 1; References:34

Running Title: Antimicrobial prescribing trends by Periodontists

Summary Sentence: Systemic antibiotics are widely used by periodontists in Australia with varying
rates and patterns for different periodontal and peri-implant conditions, we advise the need for
recommendations and guidelines in the prescription of antibiotics for periodontal and peri-implant
conditions.

*
UWA Dental School, The University of Western Australia, Perth, Australia
†
School of Dentistry and Oral Health, Griffith University, Gold Coast, Australia

This is the author manuscript accepted for publication and has undergone full peer review but has not
been through the copyediting, typesetting, pagination and proofreading process, which may lead to
differences between this version and the Version of Record. Please cite this article as doi:
10.1002/JPER.18-0586.
This article is protected by copyright. All rights reserved.
Key Words: systemic, antibiotics, prescription, periodontists, Australia

Abstract

Background: Antibiotics are a common systemic pharmaceutical therapy in periodontal conditions

for dental practitioners as well as specialists. However, there is limited information about prescribing

patterns amongst the periodontists within Australia. The objective of this study is to examine current

patterns and perceptions in prescribing systemic antibiotics for the treatment of periodontal and peri-

implant diseases.

Methods: An online questionnaire was disseminated to Australian practising members of the

Australia and New Zealand Academy of Periodontists (ANZAP) in order to determine their antibiotic

prescribing patterns for different periodontal conditions. Indications which were analysed included:

chronic periodontitis, plaque-induced gingivitis, aggressive periodontitis, acute gingival and

periodontal conditions, conditions associated with implants and implant placement, periodontal

regeneration, and mucogingival surgery.

Results: Out of the 50 members that participated in the study, 38 completed the questionnaire.

Systemic antibiotics prescription patterns varied markedly for different periodontal or peri-implant

diseases among respondents. 79% reported prescription of systemic antibiotics in the treatment of

chronic periodontitis whilst 52.6%, 55.3%, 18.4% of the respondents did so for periodontal

regeneration procedures, implant placement surgery, and mucogingival surgery, respectively.

Azithromycin, the combination of Amoxicillin and Metronidazole, and Amoxicillin were the three

most commonly prescribed systemic antibiotics.

This article is protected by copyright. All rights reserved.

Conclusion: Based on the results of this survey, systemic antibiotics are widely used by the group of

periodontists surveyed in this study in Australia with varying rates and patterns for different

periodontal and peri-implant conditions. The current study highlights the need for recommendations

and guidelines in the prescription of antibiotics for periodontal and peri-implant conditions.

Introduction

During the past three decades, periodontists have embraced the use of systemic antibiotics in

treating periodontal and peri-implant diseases due to their ability to reach microorganisms

unable to be accessed by mechanical therapy (1). The interest in antibiotic therapy for the

treatment of periodontal conditions began in the late 1970’s where it was found that certain

bacteria were frequently associated with the periodontal disease process (2). Mechanical

debridement, the mainstay of periodontal therapy, was seen to have limitations to what it

could achieve. Though this has been an effective treatment for periodontitis, it was found to

be ineffective against certain prominent periodontal pathogens such as Aggregatibacter

actinomycetemcomitans (3, 4), Porphyromonas gingivalis, Prevotella intermedia, Tannerella

forsythia, staphylococci, and enteric rods, making complete resolution of all periodontal and

peri-implant diseases challenging (5-7). Mechanical debridement may also fail to remove

pathogens within subepithelial gingival tissues, crevicular epithelium or furcal areas which

are difficult to reach (1). Antimicrobials, if used appropriately, could resolve or minimise

these issues by targeting pathogens and sites unable to be accessed by mechanical

debridement.

In comparison to local antibiotics, the systemic route of antibiotic administration offers the

advantage of distributing the antibiotic to bodily fluids such as saliva and gingival crevicular

This article is protected by copyright. All rights reserved.

fluid, thereby exposing the bacteria in subgingival and supragingival plaque to the

antibacterial agent (8, 9). However, indiscriminate use of systemic antibiotics creates the

potential problem of the development of antibiotic resistance and other adverse effects. This

problem is amplified by the fact that the microbiota of periodontal diseases includes a variety

of microorganisms with differing antimicrobial susceptibility (10) leading to the prescription

of broad-spectrum systemic antibiotics. Therefore, it is imperative to adhere to antimicrobial

stewardship principles to ensure optimal use of medications.

Dental practitioners have traditionally prescribed antibiotics with dosing regimens based

more on personal experience than evidence-based principles (1). A range of systemic

antibiotics for the treatment of periodontal and peri-implant diseases have been documented

with mixed clinical outcomes for different antibiotic therapies. This has resulted in

controversy as to the role of systemic antibiotics in the treatment and management of

periodontal and peri-implant diseases (10).

There exists a general consensus on the additional benefit that systemic antibiotics can provide to

periodontal debridement, as concluded by Herrera et. al and Haffajee et.al in their systematic reviews

(11, 12). However, due to the variation in study designs, patient populations, follow-up periods,

antibiotic types and dosages makes it difficult to achieve a consensus for clinical practice that is

capable of guiding the prescription of systemic antibiotics (13, 14).

Even though a number of studies were conducted to find out how general dentists prescribed

systemic antibiotics in treating periodontal conditions in several countries (15-19), the same

information specific to periodontists or periodontal therapy was limited (20). Furthermore,

This article is protected by copyright. All rights reserved.

there were limited studies which suggested clinical guidelines on prescription of systemic

antibiotics in periodontics (21, 22).

In Australia, there have been no therapeutic guidelines or studies investigating the patterns of

prescription of systemic antibiotics for the treatment of periodontal and/or peri-implant

diseases. Investigating how systemic antibiotics are being used for periodontal conditions will

provide valuable information to help monitor and improve patterns of systemic antibiotic

prescription in Australia.

The aim of this study was to examine current patterns and perceptions in prescribing systemic

antibiotics for the treatment of periodontal and peri-implant diseases by periodontists in Australia.

Materials and Methods

Study Sample

This was an online survey of registered periodontists in Australia, conducted during August - October

2017. The study was approved by the UWA Human Research Ethics Committee (HREC) (Number -

RA/4/1/8894). The Australian and New Zealand Academy of Periodontists (ANZAP) is the official

academy of Periodontists within Australia and New Zealand. An invitation was sent through ANZAP

mailing system to 250 Australian periodontists to participate answering an online survey. Three

reminder emails were sent over a period of two months.

Questionnaire

A cross-sectional, online questionnaire was created with the aim of examining periodontists’

antibiotic prescribing patterns and perceptions about systemic antibiotic prescription for

This article is protected by copyright. All rights reserved.

periodontal/peri-implant diseases. To ensure the quality of the study, a trial questionnaire was

conducted with periodontal registrars at the UWA Dental School. Feedback was provided by two

periodontal registrars. Subsequently, the appropriate amendments were made. Qualtrics® Research

Suite Survey software‡ was used to formulate the survey and record responses. The questionnaire was

designed to be anonymous but included information about demographic characteristics and affiliation

with educational institutions of the participating periodontists. A terms list was also included to clarify

what was meant by specific words used by the interviewers. The main body of the questionnaire

investigated the use of systemic antibiotics for a spectrum of common clinical periodontal/peri-

implant conditions and procedures. These included chronic periodontitis, plaque-induced gingivitis,

aggressive periodontitis, acute gingival and periodontal conditions, conditions associated with

implants and implant placement, periodontal regeneration, and mucogingival surgery. For each

condition/procedure, the types of systemic antibiotics used, their frequency of prescription, and order

of preference were investigated. For some of these conditions, additional questions were added

regarding the use of a combination of systemic antibiotics prescribed, in addition to the timing and

rationale for prescribing systemic antibiotics (prophylactically before or after initial periodontal/peri-

implant therapy/surgery). To discriminate the complexity of implant placement we use the ITI SAC

classification. The last two sections involved questions about side effects and observed clinical

outcomes and aimed to determine the influence of additional factors which may affect the outcome in

the prescription of systemic antibiotics. Skip logics were also introduced within the questionnaire

framework to decrease the duration of the questionnaire by ensuring irrelevant questions were not

asked based on responses to the previous questions.

‡
Qualtrics, Qualtrics Research Suite – Software version: August 2017, Provo, Utah, USA

This article is protected by copyright. All rights reserved.

Procedure

The questionnaire was sent via an anonymous link to participants through ANZAP via email so that

responses could not be identifiable. Responses were then recorded over a 2-month period from the

initial dissemination of the questionnaire, via Qualtrics® Survey software. Three reminder emails were

sent to all respondents during this period to increase the number of responses. In order to encourage

completion and return of the questionnaire, an incentive prize was supplied by Henry Schein§ in the

form of an implant starter kit, the Hu-Friedy Implacare Starter Kit**. No monetary incentive was

provided.

Data analysis

The number and percentages of respondents were determined for each question and periodontal/peri-

implant condition/procedure. Categorical variables were reported as percentages and the information

regarding the types of antibiotics, frequency of prescription and preferences used were determined by

descriptive statistics (frequency). The resultant data were displayed as tables and bar graphs. Any

statistical significance was derived from using the SPSS 24 software††.

Results

Out of the 250 potential responders as ANZAP members, 50 periodontists responded the

questionnaire. From these 50 responders, 38 completed the survey in full. Any incomplete responses

were excluded from data collection and analysis.

§
Henry Schein Halas Perth. Perth WA AUSTRALIA

**
Implacare, Hu Friedy, Mfg. Co Chicago IL USA

††
SPSS version 24.0 IBM Company, Chicago, Il, USA

This article is protected by copyright. All rights reserved.

Demographics of respondents

Of the 38 periodontists who responded demographics questions, 27/38 (71.1%) respondents were

found to have graduated from an Australian institution and 11/38 (28.9%) internationally. Of these

respondents, 22/38 (57.9%) indicated they were involved in active research or teaching roles at an

educational institution and 28/38 (73.7%) of respondents reported to have attended at least one

continuing professional development course pertaining to prescription of systemic antibiotics in

periodontics in the last two years. Periodontists who had more than 20 years of experience showed

considerably lower rates of prescribing antibiotics for the treatment of chronic periodontitis, compared

to periodontists with lower experience levels. However, this trend was not statistically significant

(p=0.07) (Table 1).

Timing of Prescription

The findings showed that systemic antibiotics were most commonly prescribed after treatment for all

periodontal conditions discussed. For the respondents who prescribed antibiotics for non-surgical

debridement in the treatment of chronic periodontitis, 76.7% (23/30) indicated that they would

prescribe after treatment and 50% (15/30) after review of initial therapy. However, none (0%) would

prescribe before and after treatment. Treating chronic periodontitis with non-surgical methods was

seen to be the only scenario in which prescribing systemic antibiotics would be considered at

periodontal re-evaluation, and not at all before and after treatment.

For surgical procedures, the remaining pattern of timings were consistent with prescribing before and

after solely after treatment being the most common timings of prescription. For chronic periodontitis

treated with surgical intervention 86.7% (13/15) of respondents who would prescribe in this scenario

would do so after treatment, and 20% (3/15) would prescribe before and after treatment. Similarly, for

implant placement surgery 57.1% (12/21) of respondents who would prescribe would do so after

This article is protected by copyright. All rights reserved.

treatment, and 38.1% (8/21) for before and after treatment, 65% (13/20) and 30% (6/20) for

periodontal regeneration, and 57.1%(4/7) and 42.9% (3/7) for mucogingival surgical procedures

respectively. Interestingly, chronic periodontitis with surgical intervention reported the highest

percentage of respondents who would prescribe systemic antibiotics when there is infection of

surgical site 46.7% (7/15). Only a small proportion of the respondents indicated that they would

prescribe antibiotics before treatment solely for all conditions listed (Figure 1).

Prescription of systemic antibiotics in different periodontal conditions

It was found that 79% (30/38) of the respondents reported prescribing systemic antibiotics for the

treatment of chronic periodontitis either as an adjunct to non-surgical or surgical debridement, or

both. No respondents 0% reported using systemic antibiotics as a monotherapy for the treatment of

chronic periodontitis. Chronic periodontitis showed the third highest prescription rate among seven

different periodontal conditions, after acute periodontal conditions for 95% (36/38) and aggressive

periodontitis for 89% (34/38) of the total respondents. Regarding surgical procedures, 21 (55%) and

20 (53%) of the 38 respondents indicated that they prescribed systemic antibiotics during the course

of implant placement surgery and periodontal regeneration procedures, respectively, while only 7

(18%) did so for mucogingival surgery. No respondents 0% indicated prescribing systemic antibiotics

for the treatment of plaque-induced gingivitis.

The percentage of patients prescribed systemic antibiotics

To determine the frequency of prescription, the percentage of patients who would be prescribed

systemic antibiotics by each respondent was determined. The majority of the respondents 80% (25/31)

who prescribed systemic antibiotics for treating chronic periodontitis with non-surgical debridement

indicated systemic antibiotics were prescribed in 1-20% of the patients. For the treatment of chronic

periodontitis when surgical debridement was used, most prescribing respondents indicated they would

This article is protected by copyright. All rights reserved.

prescribe systemic antibiotics for 3-10% (6/15) or greater than 30% (6/15) of the patients, showing

there are greater discrepancies among periodontists when surgical debridement is used. For the

treatment of aggressive periodontitis, although 89% (34/38) of respondents indicated they would

prescribe systemic antibiotics for aggressive periodontitis, the majority of the prescribing respondents

indicated they would prescribe systemic antibiotics in more than 50% (18/34) of affected patients they

see (Figure 2A).

Types of systemic antibiotics

Azithromycin was the most commonly prescribed systemic antibiotic for management of all

periodontal conditions included in the questionnaire – chronic periodontitis (non-surgical) 93.3%

(28/30) of respondents, chronic periodontitis (surgical) 73.3% (11/15), aggressive periodontitis 76.4%

(26/34), acute gingival and periodontal conditions 75% (27/36) and peri-implantitis 56.7% (17/30).

This was followed by the combination of amoxicillin and metronidazole which were the second most

commonly prescribed systemic antibiotics for all of the five periodontal conditions – chronic

periodontitis (non-surgical) 73.3% (22/30), chronic periodontitis (surgical) 53.3% (8/15), aggressive

periodontitis 67.6% (23/34), acute gingival and periodontal conditions 38.8% (14/36) and peri-

implantitis 53.3% (16/30). The use of amoxicillin standalone was particularly more common when

treating chronic periodontitis with surgical debridement 60% (9/15) compared to other periodontal

conditions discussed (2.9 – 25%). A similar trend was found with metronidazole when used for the

treatment of acute gingival and periodontal conditions 25% (9/36) vs. 5.9 – 6.7% (Figure 2B).

Acute gingival and periodontal conditions

Among the 36 of the 38 (94.7%) total respondents who indicated they prescribed antibiotics for acute

gingival and periodontal conditions, the majority of them reported they would prescribe when there

was systemic involvement. More specifically, 31/36 (86.1%) reportedly prescribed antibiotics when

This article is protected by copyright. All rights reserved.

treating acute necrotising gingivitis with systemic involvement and 28/36 (77.8%) did so for the

treatment of periodontal abscess with systemic involvement. When there was no systemic

involvement, the rates were much lower [16/36 (44.4%) and 6/36 (16.7%) respectively] (Figure 3A).

Implant placement surgery

Twenty-one respondents reported the use of systemic antibiotics during the course of implant

placement surgery, and a large proportion of these indicated they would prescribe them for advanced

and complex cases. The prescribing rates did not differ significantly for different procedures, with the

highest rate for guided bone regeneration 20/21 (95.2%) and the lowest rate when an intraoral

autogenous bone block was used 13/21 (61.9%) (Figure 3B).

Peri-implantitis

23 of the 30 respondents (76.7%) who used systemic antibiotics for the treatment of peri-implantitis

indicated the presence of suppuration as a parameter that determined the need for systemic antibiotic

use. This was followed by the presence of pocket depths equal to or more than 5mm for 20/30

(66.7%) respondents and radiographic marginal bone loss for 19/30 (63.3%). No respondents

indicated that the presence of recession was justification for systemic antibiotic use (Figure 4A).

Periodontal regeneration procedures

27 of the 32 (85%) of respondents who would use systemic antibiotics for periodontal regeneration

procedures, reported systemic antibiotic prescription when guided tissue regeneration and bone

substitute were used in conjunction with each other. The rate was significantly lower for all other

regenerative procedures, ranging from 9 – 18 of the 32 (30-55%) (Figure 4B).

This article is protected by copyright. All rights reserved.

Mucogingival surgery

All of the 7 (100%) respondents who would prescribe systemic antibiotics for mucogingival surgery

reportedly did so when an autologous/soft tissue graft was placed, while 4 (57.1%) indicated

prescribing antibiotics for allogenic procedures and only 2 (28.6%) said they prescribed for

heterologous procedures (Figure 4C).

Side Effects

To assess the prevalence of common side effects associated with systemic antibiotic prescription, we

asked periodontists what percentage of patients they observed side effects in. Generally, side effects

of systemic antibiotics were reported to be rare, with most of the respondents indicating side effects

were seen in less than 5% of patients they encountered. More commonly known and mild side effects

such as diarrhoea (40.35% of respondents indicated a prevalence of 5-30/100 patients), abdominal

pain (28.28% of respondents indicated prevalence of 5 – 30/100 patients) and nausea/vomiting

(24.48% of respondents indicated prevalence of 5 – 30/100 patients) were encountered more

frequently. Rare and relatively more severe side effects such as rashes (100% of respondents indicated

a prevalence of 0 – 5/100 patients), anaphylaxis (100% of respondents indicated a prevalence of

<1/100 patients) and jaundice (100% of respondents indicated a prevalence of <1/100 patients)

(Figure 5A) were rarely encountered amongst participants in the study.

Factors of concern

Of the 38 respondents, 31 (81.6%) indicated antimicrobial resistance as the major factor of concern

when it comes to prescribing systemic antibiotics. This was followed by side effects (76.3%), patient

compliance (52.6%) and anaphylaxis (42.1%). Corresponding to 29, 20 and 16 responders

respectively. No respondents indicated cost as a factor of concern (Figure 5B).

This article is protected by copyright. All rights reserved.

Discussion

Although systemic antibiotics have been used in periodontics for the past three decades, there has

been limited information/data available regarding current prescription patterns/trends. Periodontal

diseases are heterogeneous in nature and clinical diagnoses are made on the basis of clinical signs,

rather than molecular pathology, often without microbiological sampling (23). The present study,

although limited by several factors, provides valuable information on the current patterns of systemic

antibiotic use by periodontists in Australia.

Our results suggest that there are considerable discrepancies among periodontists in prescription

routines. For example, it was seen that some periodontists would prescribe systemic antibiotics for

more than 90 per cent of their patients for the treatment of aggressive periodontitis, whilst others

would prescribe for less than 10 per cent of patients. Our study also shows the use of systemic

antibiotics is more common when treating periodontal conditions in the absence of surgical

interventions (such as chronic periodontitis with non-surgical debridement) compared to surgical

interventions (such as implant placement surgery and mucogingival surgery). This indicates that in the

majority of such cases, the justification for use of systemic antibiotics is in reducing microbiota

involved in active disease processes rather than prophylactic use in surgical procedures. A possible

explanation for this finding may be due to the reality that periodontists treat or receive more cases

involving moderate to advanced forms of periodontitis. Our findings were seen to corroborate with the

literature where various trials reported the benefits of adjunctive use of systemic antibiotics in

combination with non-surgical debridement for the treatment of aggressive periodontitis and chronic

periodontitis (8, 11, 24, 25). 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 (12).

This article is protected by copyright. All rights reserved.

On the other hand, a review by Hererra et al. suggested that there is inadequate data as to whether

supplementing surgical periodontal therapy with systemic antibiotics was beneficial (11). A recent

systematic review performed by Park et al. found that the use of systemic antibiotics prophylactically

in healthy patients for the placement of dental implants did not appear to improve clinical outcomes

(26). Although perioperative antibiotics are commonly prescribed for certain regenerative periodontal

and implant surgeries, there has been no benefit described for their use to prevent infections post-

surgery (27). These findings stand in contrast to our data, which showed that 55% of respondents used

systemic antibiotics during implant placement and 53% for periodontal regeneration procedures.

The timing of systemic antibiotic use for all periodontal/peri-implant diseases and procedures

explored in this study was found to occur after the course of initial therapy/treatment had been

completed. Mombelli et al, and Herrera et al, already discussed the benefits in terms of timing of

antimicrobial prescription as an adjunct to the initial phase of periodontal treatment (8, 28).

Our study showed that Azithromycin is the most commonly prescribed systemic antibiotic by

periodontists in Australia. This result reflects current studies on the benefits of Azithromycin over

other antibiotics used, such as the simplicity of the treatment protocol, requiring a single three day

dose, low incidence of side effects and the rapid reduction in the bacterial load of infected sites (29,

30).

Our data also demonstrates ongoing concerns about antimicrobial resistance and side effects. Even

though our results were limited by small sample size, they distinguished between the more commonly

side effects (rash, diarrhoea, nausea/vomiting, taste alterations) and rarely encountered side and more

adverse effects such as anaphylaxis and jaundice observed by periodontists when prescribing systemic

antibiotics.

This article is protected by copyright. All rights reserved.

An interesting and important finding from the present study was that none of the periodontists used

systemic antibiotics as a monotherapy in the management of any periodontal/peri-implant diseases.

This finding is consistent with the current literature in that the effect of antibiotics alone are typically

minimal and short term as the doses used are of a short term in comparison to other medical uses, as

seen in the systematic review conducted by Haffajee et. al (12). The majority of studies do not

support the concept of monotherapy, with inferior results in terms of probing depth reduction, clinical

attachment level gain and reduction in bleeding, compared with scaling and root planning (10).

Additionally, it may be prove useful to examine whether this trend exists for the general dentist

population – particularly for gingivitis and acute periodontal conditions without systemic

involvement.

Within the literature we were only able to find one similar study investigating antimicrobial use (local

and systemic) during periodontal therapy in dental practices (general and specialist) in England and

Wales (20). In their postal survey, they were able to achieve a useable return rate of 73% (587/800)

and found antimicrobials were prescribed more frequently by Periodontal Society members in early

onset (52.7%) and refractory periodontitis patients (49.6%).

Distribution of the questionnaires via email resulted in a relatively low response rate. Only 50

periodontists responded out of 250 ANZAP members in Australia. The low response rate may have

been due to the duration of survey (10 – 15 minutes) and/or the negative public perception on

confidentiality or anonymity of online surveys (30). This presents a problem, as a high response rate

is important for validity of the conclusions and 55% has been suggested as the minimum acceptable

level (20). Studies also show that simple, plain questionnaires provide better response rates compared

to more sophisticated questionnaires (31). Even though considerable efforts were made to shorten the

duration of the questionnaire, our questionnaire covers a substantial amount of information and

This article is protected by copyright. All rights reserved.

contains 58 questions in total. Unfortunately, due to the nature of web-based assessments and the lack

of presence from the interviewers physically, motivation for respondents to see the assessment

through to the end was less likely (32).

To improve the response rate, we utilised skip logics within our online questionnaire which

significantly shortened duration of the questionnaire and prevented most respondents from having to

go through all questions unnecessarily, based on their responses to previous questions. Additionally,

three reminder emails were sent out over the two month collection period in an attempt to increase the

response rate. A physical incentive, in the form of an implant starter kit, was donated from Henry

Schein Halas as a prize in order to draw more participants. This was given to a randomly selected

member of ANZAP who had participated in the study.

The benefits of using an online questionnaire for this study included the low cost, the speed and

accuracy of data collection and reduced human error in data entry and coding. The data could also be

collected continuously regardless of time of day without geographical limitation (33). In addition to

this, use of multiple choice questions instead of open-ended questions contributed to the consistent

structure of the responses in our study.

However, the online nature also imposed a few limitations. The main limitation of our study was non-

response bias where respondents within the sample frame have different attitudes, interests or

demographic characteristics to those who did not respond (34). The respondents who answered our

questionnaire may be more interested in the use of systemic antibiotics than those who did not answer.

Another limitation of this study was that there was no way of discerning if there were several

respondents at one computer address or if one respondent was completing the questionnaire from a

variety of computers.

This article is protected by copyright. All rights reserved.

Conclusion

Our study shows that the pattern of prescribing systemic antibiotics by periodontists in Australia,

varies among individual periodontists as well as for different periodontal and peri-implant conditions.

The current study highlights the need for recommendations and/or guidelines in the prescription of

antibiotics for periodontal and peri-implant conditions. It also conveys a trend to not prescribe

antibiotics as monotherapy nor for conditions such as gingivitis and acute conditions without systemic

involvement. However, it should be noted that the current study is not sufficient to draw definitive

conclusions from surrounding the current trends in systemic antibiotic prescription, as the term ‘trend’

indicates a direction in which something is developing or changing. This must be observed over a

period of time. Consequently, the timing of the snapshot used for the cross-sectional study was not

guaranteed to be representative and should be a point of consideration for future studies in this area.

Further studies should involve assessing the effectiveness of certain antibiotics and their respective

regimens in the formulation of guidelines.

Acknowledgements

We would like to acknowledge the Australian and New Zealand Academy of Periodontists for their

participation and support with this study, Henry Schein Halas for their generosity with a price

donation and Dr. Joon Soo Park for his assistance in the editing process of this paper.

Conflict of Interest

The authors declare that they don’t have any conflict of interest in relation to this project.

This article is protected by copyright. All rights reserved.

References

1. Slots J, Ting M. Systemic antibiotics in the treatment of periodontal disease.

Periodontol 2000. 2002;28:106-76.

2. Patil V, Mali R, Mali A. Systemic anti-microbial agents used in periodontal therapy.

J Indian Soc Periodontol. 2013;17(2):162-8.

3. Mombelli A, Gmur R, Gobbi C, Lang NP. Actinobacillus actinomycetemcomitans in adult

periodontitis. I. Topographic distribution before and after treatment. J Periodontol.

1994;65(9):820-6.

4. van Winkelhoff AJ, Tijhof CJ, de Graaff J. Microbiological and clinical results of

metronidazole plus amoxicillin therapy in Actinobacillus actinomycetemcomitans-associated

periodontitis. J Periodontol. 1992;63(1):52-7.

5. Edwardsson S, Bing M, Axtelius B, Lindberg B, Soderfeldt B, Attstrom R. The microbiota

of periodontal pockets with different depths in therapy-resistant periodontitis. J Clin

Periodontol. 1999;26(3):143-52.

6. Mombelli A, Schmid B, Rutar A, Lang NP. Persistence patterns of Porphyromonas

gingivalis, Prevotella intermedia/nigrescens, and Actinobacillus actinomyetemcomitans after

mechanical therapy of periodontal disease. J Periodontol. 2000;71(1):14-21.

7. Petersilka GJ, Ehmke B, Flemmig TF. Antimicrobial effects of mechanical debridement.

Periodontol 2000. 2002;28:56-71.

8. Herrera D, Alonso B, Leon R, Roldan S, Sanz M. Antimicrobial therapy in periodontitis:

the use of systemic antimicrobials against the subgingival biofilm. J Clin Periodontol.

2008;35(8 Suppl):45-66.

9. Baker PJ, Evans RT, Coburn RA, Genco RJ. Tetracycline and its derivatives strongly

bind to and are released from the tooth surface in active form. J Periodontol.1983;54(10):580-

5.

This article is protected by copyright. All rights reserved.

10. Heitz-Mayfield LJ. Systemic antibiotics in periodontal therapy. Aust Dent J. 2009;54

Suppl 1:S96-101.

11. Herrera D, Matesanz P, Bascones-Martinez A, Sanz M. Local and systemic

antimicrobial therapy in periodontics. The Journal of Evidence Based Dental Practice.

2012;12(3 Suppl):50-60.

12. Haffajee AD, Socransky SS, Gunsolley JC. Systemic anti-infective periodontal therapy. A

systematic review. Ann Periodontol. 2003;8(1):115-81.

13. Genco RJ. Using antimicrobial agents to manage periodontal diseases. J Am Dent

Assoc. 1991;122(9):30-8.

14. Heitz-Mayfield LJ, Mombelli A. The therapy of peri-implantitis: a systematic review.

Int J Oral Maxillofac Implants. 2014;29 Suppl:325-45.

15. Vessal G, Khabiri A, Mirkhani H, Cookson BD, Askarian M. Study of antibiotic

prescribing among dental practitioners in Shiraz, Islamic Republic of Iran. East Mediterr

Health J. 2011;17(10):763-9.

16. Peric M, Perkovic I, Romic M, Simeon P, Matijevic J, Mehicic GP, et al. The Pattern

of Antibiotic Prescribing by Dental Practitioners in Zagreb, Croatia. Cent Eur J Public

Health. 2015;23(2):83-9.

17. Johnson TM, Hawkes J. Awareness of antibiotic prescribing and resistance in primary

dental care. Prim Dent J. 2014;3(4):44-7.

18. Cope AL, Francis NA, Wood F, Chestnutt IG. Antibiotic prescribing in UK general

dental practice: a cross-sectional study. Community Dent Oral Epidemiol. 2016;44(2):145-

53.

19. Halboub E, Alzaili A, Quadri MF, Al-Haroni M, Al-Obaida MI, Al-Hebshi NN.

Antibiotic Prescription Knowledge of Dentists in Kingdom of Saudi Arabia: An Online,

Country-wide Survey. J Contemp Dent Pract. 2016;17(3):198-204.

This article is protected by copyright. All rights reserved.

20. Choudhury M, Needleman I, Gillam D, Moles DR. Systemic and local antimicrobial

use in periodontal therapy in England and Wales. J Clin Periodontol. 2001;28(9):833-9.

21. Blair FM, Chapple IL. Prescribing for periodontal disease. Prim Dent J. 2014;3(4):38-43.

22. Gillam DG, Turner W. Antibiotics in the treatment of periodontal disease: a guide for

the general dental practitioner. Prim Dent J. 2014;3(3):43-7.

23. Kapoor A, Malhotra R, Grover V, Grover D. Systemic antibiotic therapy in periodontics.

Dent Res J (Isfahan). 2012;9(5):505-15.

24. Keestra JA, Grosjean I, Coucke W, Quirynen M, Teughels W. Non-surgical periodontal

therapy with systemic antibiotics in patients with untreated aggressive periodontitis: a

systematic review and meta-analysis. J Periodontal Res. 2015;50(6):689-706.

25. Renatus A, Herrmann J, Schonfelder A, Schwarzenberger F, Jentsch H. Clinical

Efficacy of Azithromycin as an Adjunctive Therapy to Non-Surgical Periodontal Treatment

of Periodontitis: A Systematic Review and Meta-Analysis. J Clin Diagn Res.

2016;10(7):ZE01-7.

26. J Park, M Tennant, LJ Walsh, E Kruger. Is there a consensus on antibiotic usage for

dental implant placement in healthy patients? Aust Dent J. 2018;63(1):25-33.

27. Powell CA, Mealey BL, Deas DE, McDonnell HT, Moritz AJ. Post-surgical infections:

prevalence associated with various periodontal surgical procedures. J Periodontol.

2005;76(3):329-33.

28. Andrea Mombelli, Norbert Cionca and Adnan Almaghlouth. Does adjunctive

antimicrobial therapy reduce the perceived need for periodontal surgery?

Periodontology 2000, vol. 55, 2011, 205–216

29. Muniz FW, de Oliveira CC, de Sousa Carvalho R, Moreira MM, de Moraes ME, Martins

RS. Azithromycin: a new concept in adjuvant treatment of periodontitis. Eur J

Pharmacol. 2013;705(1-3):135-9.

This article is protected by copyright. All rights reserved.

30. R. Hirsch, H. Deng and M. N. Laohachai, Azithromycin in periodontal treatment: more

than an antibiotic, J Periodontal Res, 47, 2, (137-148), (2011).

31. van Selm M, Jankowski NW. Conducting Online Surveys. Quality and Quantity.

2006;40(3):435-56.

32. Dillman D, State W, Tortora D, Conradt J, Organization G. Influence of Plain Vs. Fancy

Design On Response Rates. 1999.

33. Heiervang E, Goodman R. Advantages and limitations of web-based surveys: evidence

from a child mental health survey. Soc Psychiatry Psychiatr \Epidemiol.

2011;46(1):69-76.

34. Fleming CM, Bowden M. Web-based surveys as an alternative to traditional mail

methods. J environ manage. 2009;90(1):284-92.

This article is protected by copyright. All rights reserved.

Figure Legend

Figure 1. Timing of systemic antibiotic prescription for specific periodontal/ peri-implant

conditions/procedures.

Figure 2A. Percentage of patients who would be prescribed antibiotics for periodontal
conditions.

This article is protected by copyright. All rights reserved.

Figure 2B. Types of systemic antibiotics prescribed for periodontal/peri-implant conditions
amongst periodontists.

Figure 3A. Percentage of respondents who would prescribe systemic antibiotics for specific
acute gingival and periodontal conditions (n=36)

Figure 3B. Percentage of the prescribing respondents who would prescribe systemic
antibiotics for different implant placement surgical procedures and case complexities. (n=21)

This article is protected by copyright. All rights reserved.

Figure 4A. Percentage of respondents who recognised certain peri-implant disease
parameters as significant determinants of systemic antibiotic prescription in peri-implantitis
(n=30)

Figure 4B. Percentage of respondents who would prescribe systemic antibiotics when faced
with different periodontal regeneration procedures (n=20)

This article is protected by copyright. All rights reserved.

Figure 4C. Percentage of the prescribing respondents who would prescribe systemic
antibiotics for different mucogingival surgical procedures (n=7)

Figure 5A. Percentages of patients respondents observed as experiencing common side

effects after being prescribed systemic antibiotics by periodontists (n=38)

This article is protected by copyright. All rights reserved.

Figure 5B. Factors of concern associated with prescription of systemic antibiotics, as
reported by respondents (n=38)

This article is protected by copyright. All rights reserved.

Table 1. Frequency distribution of respondents with different levels of clinical experience on use of
systemic antibiotics (n=38). CPD Continuing Professional Development

Country and Institution of Postgraduate studies (N=38)

International 11 (28.9%) Domestic 27 (71.1%)

Number of years practicing as a periodontist (N=38)

1 – 5 years 8 (21.1%)

6 – 10 years 7 (18.4%)

11 – 15 years 6 (15.8%)

16 – 20 years 5 (13.2%)

> 20 years 12 (31.6%)

Total 38

Sector of work (N=38)

Private 26 (68.4%) Public 4 (10.5%) Both 8 (21.1%)

Affiliation with educational institution i.e. research or teaching (N=38)

Yes 22 (57.9%) No 16 (42.1%)

Attended a CPD course within last 2 years pertaining to the use and/or prescription of systemic
antibiotics in periodontics (N=38)

Yes 28 (73.7%) No 10 (26.3%)

Does the socio-economic status of your patients influence your decision to prescribe systemic
antibiotics? (N=38)

Yes 2 (5.3%) No 36 (94.7%)

This article is protected by copyright. All rights reserved.