Periodontology 2000, Vol. 67, 2015, 131186 2014 John Wiley & Sons A/S.
& Sons A/S. Published by John Wiley & Sons Ltd
Printed in Singapore. All rights reserved
Systemic antibiotics in the
treatment of periodontitis
M A G D A F E R E S , L U C I E N E C. F I G U E I R E D O , G E I S L A M. S I L V A S O A R E S &
MARCELO FAVERI
The recognition of the microbial origin and speci-
city of periodontal diseases in the late 1970s led
to an increased interest in the use of antimicro-
bial agents in periodontal therapy to promote a
selective suppression of the probable etiologic
agents. Since then, several groups of investigators
have started to examine the effect of systemically
administered antibiotics as adjuncts to conven-
tional periodontal treatment, such as scaling and
root planing. Unfortunately, for several years the
results of these investigations were inconclusive
and often contradictory, especially regarding the
effect of these agents on the microbial composi-
tion of subgingival biolm. This was largely a
result of limitations of the microbiological tech-
niques available, as well as a lack of standardiza-
tion of the clinical study designs. The major
advances in laboratory and clinical research
methods in the past decade have led to well-
designed randomized clinical trials using cutting-
edge diagnostic tests that have greatly contributed
to determining the actual outcomes of several
periodontal treatments. This article endeavored to
provide a state of the art overview on the use of
systemic antibiotics in the treatment of periodon-
titis, based on the most recent literature on this
topic as well as on a compilation of data from
studies conducted at the Center of Clinical Trials
at Guarulhos University (Sa ~o Paulo, Latin Amer-
ica, Brazil) from 2002 to 2012. In order to provide
a better biological understanding of the use of
these antimicrobials in periodontal treatment, the
rst part of this article presents an overview of
some recent microbiological/ecological concepts
associated with the etiology of periodontal infec-
tions.
Microbiological basis for
periodontal treatment
The periodontal pathogens: a long search
The effective treatment of an infectious disease is
dependent on accurate diagnosis of the microorgan-
ism(s) implicated in its etiopathogenesis. This is not
always an easy goal to achieve, especially in cases of
mixed infections in areas of the body that are natu-
rally contaminated with bacteria, such as the gastro-
intestinal tract and oral cavity. Technical difculties
in evaluating the complex subgingival microbiota,
which is highly colonized by several species of strict
anaerobes and fastidious pathogens, have greatly
delayed the correct diagnosis and treatment of peri-
odontitis (197). New targeted diagnostic techniques,
not dependent on the viability of the bacteria for their
identication, such as immunoassays, PCR and DNA
probes, were introduced in the late 1980s and early
1990s and gave rise to the modern search for the eti-
ological agents of destructive periodontal diseases
(12, 32, 106, 199, 213, 224). From that time until recent
years these technologies have been further improved,
and the introduction of high-throughput microbial
diagnostic techniques have promoted a rapid
advance in our understanding of the complex subgin-
gival microbial composition. The results of these
studies conrmed and extended data from early
investigations about the role of certain microorgan-
isms, including Aggregatibacter actinomycetemcomi-
tans, Porphyromonas gingivalis, Treponema denticola,
Tannerella forsythia, Prevotella intermedia, Parvi-
monas micra, Fusobacterium nucleatum, Selenomon-
as sputigena and Eubacterium nodatum, in the onset
and progression of periodontitis (17, 31, 36, 37, 48, 62,
131
Feres et al.
65, 70, 71, 76, 124, 134, 147, 193, 201, 206, 207, 217).
More recently, the introduction of open-ended
molecular diagnostic tests, including next-generation
sequencing methods, rekindled the search for new
periodontal pathogens. The combined results of the
studies using targeted and open-ended tests suggest
that some other cultivable and not-yet cultivable/
unrecognized microbial species might play a role in
the etiology of periodontitis. Some of the novel candi-
date pathogens are species or phylotypes from the
genera Bacteroidetes (e.g. Porphyromonas endodon-
talis and Bacteroidales [G-2] sp. oral taxon 274), Spiro-
chaetes (e.g. Treponema lecithinolyticum and
Treponema medium), Firmicutes (e.g. Filifactor alocis
and S. sputigena) and Synergistetes (e.g. Fretibacteri-
um sp. oral taxon 360 and Fretibacterium fastidiuo-
sum) (48, 54, 102, 103). The phylum Candidatus
saccharibacteria (TM7), the Archaea domain and her-
pesviruses might also have an association with
disease (107, 109, 131, 153, 185).
In addition to this evident growth in our knowledge
about the role of different pathogens in the etio-
pathogenesis of periodontitis, some new ecological
concepts generated in the medical and dental elds
in the past decades have also contributed to changing
several paradigms in periodontal treatment. Some of
these concepts are discussed below.
Ecological concepts in the treatment of
periodontal diseases: the role of host-
compatible species and the importance
of dening microbial proles
One of the most important contributions of the mod-
ern era of oral microbiology was probably the notion
introduced by Socransky and coworkers in the late
1980s that not all bacterial species existing in the oral
cavity are pathogenic. In fact, some are host-compati-
ble or even benecial (195, 196, 200). The species con-
sidered as benecial included Veillonella parvula, more specic treatments was rapidly recognized and
Actinomyces sp., or the combination of Streptococcus
oralis, Streptococcus mitis and Streptococcus interme-
dius. Clusters of these microorganisms were observed
in samples from sites that exhibited less active disease
and responded more favorably to therapy (195). This
concept was extended and largely disseminated after
the publication of the classic study Microbial com-
plexes in subgingival plaque (193). Using cluster
analysis and community ordination techniques, the
authors evaluated the composition of 13,261 subgin-
gival biolm samples from 160 subjects with chronic
periodontitis and 25 with periodontal health using
40 DNA probes for host-compatible species and
132
periodontal pathogens. Three microbial complexes
yellow, purple and green harbored several species
considered to be host-compatible, including V. parv-
ula, Actinomyces odontolyticus, Streptococcus and
Capnocytophaga species. Later on, a group of four
Actinomyces species was also pointed out as being
important benecial microorganisms (194). These
microbial species were considered as early colonizers
of the tooth surface, whose growth usually precedes
the multiplication of the predominantly gram-nega-
tive species from the pathogenic orange and red com-
plexes. The orange complex harbored 12 bacterial
species, including Fusubacterium and Campylobacter
species, E. nodatum, P. intermedia, Prevotella nigres-
cens and Streptococcus constellatus. The red complex
consisted of three closely related pathogens T. for-
sythia, P. gingivalis and T. denticola which were
detected at higher proportions in diseased sites than
in periodontally healthy sites and were strongly asso-
ciated with probing depth and bleeding on probing.
These ndings played a major role in our under-
standing of the etiology of periodontal diseases, espe-
cially chronic periodontitis. Furthermore, the results
of these studies suggest that in order to obtain thera-
peutic success, it is as important to foster the over-
growth of host-compatible bacterial species as it is to
eliminate or suppress the periodontal pathogens.
Therefore, in order to establish more effective treat-
ments for periodontitis, one would have to track not
only the presence or absence of a few pathogens
before and after treatment but the changes occurring
in the entire subgingival microbial prole. It is dif-
cult to measure the impact of these ndings on the
periodontal research eld. Only to provide the reader
with a reference, the paper outlined above, Microbial
complexes in subgingival plaque (193) has been cited
over 900 times since its publication in 1998 (209).
The importance of dening the microbial proles of
different periodontal conditions in order to delineate
this motivated groups of investigators to evaluate
large numbers of biolm samples for the presence,
levels and proportions of several pathogens, as well as
host-compatible bacterial species. Initially, the micro-
bial prole of chronic periodontitis, the most common
periodontal condition, was dened in different geo-
graphic locations (23, 62, 65, 124, 216), and the results
of these studies were largely in agreement with the
study of Socransky et al. (193) in subjects from the
USA. However, information about less-prevalent con-
ditions, such as localized and generalized aggressive
periodontitis in young subjects, took a little longer to
become available (36, 84). Figure 1 contains an exten-

Fig. 1. Pie charts describing the mean proportions of
microbial complexes in subgingival biolm samples taken
from 50 subjects with periodontal health, 15 subjects with
localized aggressive periodontitis, 56 subjects with gener-
alized aggressive periodontitis and 290 subjects with
chronic periodontitis. Nine subgingival biolm samples
were taken from each subject and were analyzed sepa-
rately to determine their content of the 40 species of bac-
teria listed in Fig. 2. The percentage of DNA probe counts
for each species was determined at each site, then aver-
aged within a subject and then across subjects in each
sion of the data described by Faveri et al. (36), who,
for the rst time, evaluated the microbial prole of a
group of young subjects with localized aggressive peri-
odontitis. The data presented in Fig. 1 provide a com-
parison between the microbial proles of 50 subjects
with periodontal health, 290 with chronic periodonti-
tis, 56 with generalized aggressive periodontitis and 15
with localized aggressive periodontitis. The bacterial
species were organized according to the microbial
proles described by Socransky et al. (193), four Acti-
nomyces species are shown in blue and A. actinomyce-
temcomitans in light green. In agreement with
previous investigations (79, 80, 126, 219, 222), A. ac-
tinomycetemcomitans was found in signicantly
higher proportions in subjects with aggressive peri-
odontitis in comparison with those with chronic peri-
odontitis or with periodontal health, who harbored
very low proportions (<1%) of this pathogen. How-
ever, one point of note was the high proportions of
red complex species in all three periodontitis groups.
This was an expected nding for subjects with chronic
periodontitis, but quite unexpected for very young
subjects with localized disease (mean age, 15.2 years).
To date, only a few previous studies have suggested
that pathogens other than A. actinomycetemcomitans
could also be associated with the etiology of localized
aggressive periodontitis (44, 121, 145). Moreover, as
one moves from health to disease, a signicant
decrease in the proportions of Actinomyces species
was observed, which was also expected. The novel
Systemic antibiotics in periodontal therapy
group. The mean proportion of each species was summed
in order to determine the proportion of each complex.
The colors represent the different complexes described by
Socransky et al. (193). Actinomyces spp. are represented
in blue and A. actinomycetemcomitans in light green.
The grey color represents species that did not fall into
any complex. The signicance of differences among
groups was determined using analysis of covariance,
adjusted for mean age and Tukeys multiple comparison
tests (different letters indicate signicant differences
among groups).
and interesting information about the host-compati-
ble Actinomyces was their very low proportions in
localized and generalized periodontitis in comparison
with chronic periodontitis. These data might explain
the lower degree of plaque accumulation observed in
aggressive periodontitis because the Actinomyces are
important plaque formers. Furthermore, these bacte-
rial species have been strongly associated with healthy
patients (23, 124, 198) and their increased proportions
may be necessary for a successful therapeutic out-
come. These ndings provide the basis for determin-
ing microbiological endpoints for therapy. The overall
similarity among the microbial proles of the three
disease conditions, as well as the higher proportions
of red complex bacteria and lower proportions of Acti-
nomyces species in all periodontitis groups in compar-
ison with the healthy group, suggest that the
therapeutic protocols for these infections may not
vary substantially.
Ecological concepts in the treatment of
periodontal diseases: pathogens are
located in the entire mouth, not only in
deep periodontal pockets
Historically, the treatment of periodontal diseases has
been largely focused on deep periodontal pockets.
There is an overall consensus that scaling and root
planing should be restricted to intermediate and deep
pockets, and that shallow sites should be avoided.
133
Feres et al.

The rationale for this thought was the results from
studies which showed that shallow sites might lose
attachment after scaling and root planing (64, 83,
164). In addition, it has been recognized that the
presence of deep pockets after treatment is an impor-
tant risk factor for further disease progression (132,
133) and comprehensive studies have shown that
periodontal pathogens are more concentrated in
deep pockets (71, 198). Therefore, focusing periodon-
tal treatment to deep pockets may be considered as
almost an obvious and effective strategy. A less well-
known factor is that even shallow pockets of subjects
with periodontitis can be highly colonized with sev-
eral periodontal pathogens, a very unfortunate nd-
ing in the light of the current overall idea of treating
mostly deep pockets. This statement is illustrated in
Fig. 2, which presents the mean counts and propor-
tions of 40 bacterial species in nonbleeding shallow
(healthy) sites, with probing depth 4 mm, in a
group of 295 subjects with advanced periodontitis, as
well as in 50 periodontally healthy individuals. The
mean levels of 32 out of 40 bacterial species evaluated
were statistically signicantly elevated in the peri-
odontitis subjects (Fig. 2, left panel), which was a
somewhat expected result because these subjects
normally present higher overall plaque levels. The
most interesting observation relates to the composi-
tion of the subgingival microbial prole in the two
groups (Fig. 2, right panel). The healthy sites of sub-
jects with periodontitis presented statistically signi-
cantly higher mean proportions of some of the most
important periodontal pathogens, such as A. actino-
mycetemcomitans, the three members of the red com-
plex (T. forsythia, P. gingivalis and T. denticola) and
four from the orange complex (Campylobacter rectus,
E. nodatum, P. micra and P. intermedia) in compari-
son with the healthy sites in periodontally healthy
subjects. On the other hand, the overall proportion of

Counts x 105 DNA probe counts (%)

0.0 5.7 11.4 17.1 22.8 0.0 6.3 12.7 19.0 25.3

A.gerencseriae
A.israelii *** Actinomyces
A.naeslundii ***
A.oris ***
A.odontolyticus
V.parvulla
** Purple
S.gordonii
S.intermedius
***
S.mitis
***
*** Yellow
S.oralis
S.sanguinis ***
A. actinomycetemcomitans ***
C.gingivalis *** ***
C.ochracea Green
C.sputigena
*
E.corrodens
**
C.gracilis
***
C.rectus * Periodontitis n = 295
C.showae *** ***
E.nodatum * Periodontal health n = 50
F.nucleatum.ssp.nucleatum *** Orange ***
F.nucleatum.ssp.polymorphum
***
F.nucleatum.ssp.vincentii
***
F.periodonticum
**
P.micra
**
P.intermedia *** ***
P.nigrescens *** ***
S.constellatus *
T.forsythia ***
P.gingivalis
*** ***
T.denticola Red
*** ***
E.saburreum
*** ***
G.morbillorum
*** ***
L.buccalis **
P.acnes *** Others
P.melaninogenica
N.mucosa
S.anginosus
S.noxia
T.socranskii
*
**
Fig. 2. Proles of the mean counts (3105; left panel) and grouped according to the microbial complexes described
of mean proportions (%; right panel) of 40 taxa in sub- by Socransky et al. (193). The mean values for each spe-
gingival biolm samples taken from nonbleeding shallow cies were averaged within a subject and then across sub-
sites (probing depth 4 mm) of 295 subjects with peri- jects in the two clinical groups. The signicance of
odontitis and 50 subjects with periodontal health. Three differences between groups was determined using the
subgingival biolm samples were taken from each subject MannWhitney U-test adjusted for multiple comparisons
and were analyzed separately to determine their content [Socransky et al. (199)]; * P < 0.05; ** P < 0.01; ***
of 40 species of bacteria. The species were ordered and P < 0.001.

134
Feres et al.

SRP SRP+AZT SRP+MTZ+AMX

DNA probe counts (%) 0.0 4.6 9.1 13.7 18.3 0.0 4.6 9.1 13.7 18.3 0.0 4.6 9.1 13.7 18.3

A.gerencseriae
A.israelii *
A.naeslundii Actinos
A.oris ** **
A.odontolyticus Purple
V.parvulla
S.gordonii
S.intermedius **
Yellow
S.mitis
S.oralis
S.sanguinis
A. actinomycetemcomitans **
C.gingivalis
C.ochracea Green
C.sputigena
E.corrodens
C.gracilis
C.rectus
C.showae **
Baseline
E.nodatum
F.nucleatum.ssp.nucleatum 6 months
Orange 1 year
F.nucleatum.ssp.polymorphum
F.nucleatum.ssp.vincentii
F.periodonticum
P.micra
P.intermedia
P.nigrescens
S.constellatus
T.forsythia **
P.gingivalis Red ***
*** *** ***
T.denticola
E.saburreum ***
G.morbillorum
L.buccalis
P.acnes Others
P.melaninogenica
N.mucosa
S.anginosus
S.noxia
T.socranskii

Fig. 6. Proles of the mean proportions (%) of 40 taxa in
subgingival biolm samples taken from subjects with very
advanced periodontitis treated with scaling and root
planing (SRP) alone (n = 15), combined with 500 mg of
azithromycin (once a day for 5 days) (SRP+AZT)
(n = 15) or combined with 400 mg of metronida-
zole + 500 mg of amoxicillin (three times daily for 14 days)
(SRP+MTX+AMX) (n = 15), at baseline, and at 6 months
and 1 year post-treatment. Nine subgingival biolm sam-
ples were taken from each subject at each time point and
were analyzed separately to determine their content of 40
species of bacteria. The species were ordered and grouped
according to the microbial complexes described by Socran-
sky et al. (193). The percentage of DNA probe counts for
each species was determined at each site, then averaged
within a subject and then across subjects in each group at
each time point. The signicance of differences among
time points was determined using the Friedman test
adjusted for multiple comparisons [Socransky et al. (199)]
(*P < 0.05; **P < 0.01; ***P < 0.001).

prole than that of azithromycin. It may be observed
that scaling and root planing + metronidazole +
amoxicillin was the only treatment that signicantly
reduced the proportions of the three pathogens of the
red complex. Moreover, this treatment was able to
increase the proportions of three benecial bacterial
species (Actinomyces gerencseriae, A. naeslundii and
Streptococcus sanguinis as opposed to only one in the
azithromycin group (A. naeslundii). Even though scal-
ing and root planing also led to the increase of some
host-compatible species, these changes were not sta-
tistically signicant from baseline to 1 year in this
group. Figure 7 shows the changes that occurred in
the microbial complexes with the use of the different
treatments. All three treatments caused a benecial
change in the microbial prole; however, one impor-
tant aspect to point out in this gure is the residual
mean proportion of red complex in the three groups.
These species accounted for approximately 12% of
the 40 species evaluated in the scaling and root
planing and azithromycin groups, and for 4.9% in
the metronidazole + amoxicillin group. Previous
publications have demonstrated a mean of 10%
remaining red complex in subjects with advanced
periodontitis treated by scaling and root planing, but
this proportion is noticeably lower (33.5%) when sys-
temic antibiotics are used as adjunct to the mechani-
cal treatment (130, 138, 184). Therefore, 12%
remaining mean proportions of red complex in the
azithromycin-treated subjects was a rather
disappointing result and is probably one of the major
reasons for the lack of an additional clinical effect of
azithromycin over that obtained with scaling and root
planing only, as recently highlighted by Sampaio

162
Feres et al.
parameters used in the analyses conducted in this
section were:

To compare different treatments (i.e. primary clin-
ical outcome variable): the mean number of resid-
ual sites with probing depth 5 mm.

To dene excellent treatment response (i.e. clini-
cal endpoint for treatment): the presence of 4
sites with probing depth 5 mm (low risk for fur-
ther disease progression).
Microbiological outcomes
Several recent studies assessing the effects of different
periodontal therapies on the composition of the sub-
gingival microbiota have shown that effective clinical
results are obtained when the levels and proportions
of periodontal pathogens are reduced or eliminated
and the root surfaces are recolonized with a new bio-
lm community harboring higher proportions of
host-compatible species (22, 26, 30, 66, 71, 108, 130,
138, 184). This is a complex ecological shift that
involves a striking change in the levels and propor-
tions of several bacterial species, making the deni-
tion of the microbial endpoint for periodontal
treatment a rather challenging task.
In an attempt to dene objective microbial end-
points for periodontal treatment, we evaluated the
microbial composition of the best-responders sub-
jects, among those treated with scaling and root
planing, alone, or combined with systemic antibiot-
ics (Table 1). A subject was considered to be among
the best-responders, and therefore included in this
analysis, if he/she presented with at most four sites
with a probing depth of 5 mm (i.e. a low-risk pro-
le for further disease progression) (105, 132, 133) at
3 months post-treatment, and maintained this pro-
le for up to 1 year. At 3 months post-treatment,
the mean proportions of the red complex in this
group of subjects were 2.7%; the upper quartile was
4.2% and the median was 1.5%. Thus, the three red
complex species summed, represented at most 4.2%
of all 40 species evaluated in 75% of these subjects.
Conversely, the mean proportions of Actinomyces
were 26.8%; the lower quartile was 15.1% and the
median was 24.1%. Thus, these four host-compatible
Actinomyces species summed, represented at least
15.1% of all 40 species evaluated in 75% of these
subjects.
Therefore, the microbial parameters used in the
analyses conducted in this section were as follows.

to compare different treatments (i.e. primary
microbiological outcome variable): mean percent-
age of red complex species.
136

to dene excellent treatment response (i.e. micro-
biological endpoints for treatment): the presence
of 4.2% of red complex species and 15.1% of
Actinomyces species.
Rationale for the use of adjunctive
antibiotics in the periodontal treatment
Scaling and root planing has been considered the
gold standard treatment for periodontitis for almost
100 years. The results of the studies that evaluated
the clinical effects of scaling and root planing suggest
an overall benet in terms of reducing the percentage
of sites presenting bleeding on probing and suppura-
tion as well as a reduction in probing depth and a
gain in clinical attachment (8, 20, 22, 26, 63, 83, 162,
164). However, scaling and root planing does not lead
to major clinical improvements in all subjects, espe-
cially in cases of advanced disease and deep peri-
odontal pockets (50, 113, 177). This is probably
because scaling and root planing alone does not
cause a sufciently deep change in the subgingival
microbial composition to achieve and maintain a
prole compatible with periodontal health longitudi-
nally (144, 177, 184). In order to test this hypothesis,
we gathered the data of 75 subjects with advanced
periodontal disease treated with scaling and root
planing, who were clinically and microbiologically
monitored at baseline, 3 months, 6 months and
1 year post-treatment, and the results are presented
in Fig. 3 and in Tables 2 and 3. The mean baseline
probing depth and clinical attachment level for this
group of subjects were 3.9 mm and 4.4 mm, respec-
tively. The mean reduction in probing depth and gain
in clinical attachment (Table 2) were beyond the
expected changes for scaling and root planing accord-
ing to a meta-analysis (90) and a comprehensive
review (20). There was a statistically signicant reduc-
tion in the mean number of residual sites with prob-
ing depth 5 mm, 6 mm and 7 mm from baseline
to 3 months, which in general, was maintained at
6 months and 1 year post-treatment (Table 3). Nev-
ertheless, the mean number of residual sites with
probing depth 5 mm was still high at 1 year
(17.9  15.2) and only 16% (12/75) of the subjects
treated with scaling and root planing reached the
clinical endpoint for treatment (i.e. presented at most
four sites with probing depth 5 mm). The mean pro-
portions of the microbial complexes at baseline and
after treatment are presented in Fig. 3. An improve-
ment in the subgingival microbial composition
occurred at 3 months, as may be noticed by a statisti-
cally signicant reduction in the mean proportions of
 Systemic antibiotics in periodontal therapy

Table 1. Microbial characteristics of subgingival biolm of best responders subjects

Variables Mean SD Median LQ-UQ

Mean counts 910 5

A. gerencseriae 3.14 3.61 2.33 1.323.49

A. israelii 3.39 4.91 2.00 1.423.50

A. naeslundii 2.47 2.72 1.96 1.133.01

A. oris 18.11 14.56 15.24 5.5126.28

T. forsythia 4.1 9.50 0.6 0.02.4

P. gingivalis 1.8 4.01 0.1 0.01.1

T. denticola 0.8 1.85 0.2 0.01.0

Actinomyces sp.* 26.65 19.92 20.08 14.1436.21

Purple complex 11.28 10.14 5.58 3.1416.80

Yellow complex 23.26 24.92 11.67 4.8936.89

Green complex 11.37 16.98 5.02 2.5411.29

Orange complex 29.05 33.92 18.84 4.3139.46

Red complex 6.59 11.28 1.46 0.116.84

Others 26.07 24.90 20.52 6.8839.42

Mean proportions (%)

A. gerencseriae 2.59 1.95 2.33 1.183.37

A. israelii 2.95 2.84 2.29 1.203.55

A. naeslundii 2.76 3.62 1.61 0.543.17

A. oris 18.97 14.53 14.75 8.5821.33

T. forsythia 1.75 2.92 0.34 0.002.00

P. gingivalis 0.69 1.23 0.07 0.000.74

T. denticola 0.35 0.58 0.14 0.000.48

Actinomyces sp.* 26.8 17.9 24.1 15.132.0

Purple complex 9.47 7.54 8.13 4.7611.62

Yellow complex 15.65 10.90 14.38 7.3123.15

Green complex 8.00 9.21 5.20 2.129.26

Orange complex 17.49 11.71 16.37 7.6723.08

Red 2.74 3.50 1.50 0.07 4.23

Others 19.88 12.47 18.63 12.4026.54

% sites colonized at levels 10 5

T. forsythia 8.0 9.0 3.0 0.017.0

P. gingivalis 5.0 6.0 0.0 0.08.0

T. denticola 3.0 2.0 0.0 0.06.0

All red complex spcs. 1.0 2.0 0.0 0.03.0

The samples were taken from 45 subjects who showed a very good clinical response (best responders subjects) at 3 months post-treatment (i.e. presented at most
four sites with PD 5 mm the clinical endpoint for treatment) and maintained this clinical prole for up to 1 year. Nine subgingival biolm samples were taken
from each subject at 3 months.
*Including Actinomyces gerencseriae, Actinomyces israelii, Actinomyces naeslundii and Actinomyces oris.

137

two groups also presented the greatest gain in clini-
cal attachment at initially deep sites in comparison
with those treated with scaling and root planing
only (P < 0.05) (Table 17). In accordance with the
clinical changes, the most striking benecial changes
in the subgingival microbial composition were
observed in the two test groups receiving the
systemic antibiotics for 14 days (Figs 12 and 13).
Subjects in all antibiotic groups showed a statisti-
cally signicant reduction in the individual levels of
the three red complex pathogens (T. forsythia, P.
gingivalis and T. denticola) but the two groups with
the longer period of antibiotic administration
(14 days) also had a reduction in ve putative
pathogens from the orange complex, against one or
two species in the other three groups (Fig. 12). In
addition, at 3 months post-therapy, these two test
groups, but not those two taking the antibiotics for
7 days, showed statistically signicantly lower
residual mean proportions of red complex (5.7% for
250 mg of metronidazol; 5.1% for 400 mg of
A days antibiotic regimen were less evident.
16.0
Red complex
(T. forsythia, P. gingivalis and T. denticola)
12.0
Mean proportion (%)
8.0
4.0
0.0
SRP MTZ 250 mg MTZ 400 mg MTZ 250 mg
7 days
Fig. 13. Bar charts of the mean proportions of the three
red complex bacterial species (Tannerella forsythia, Por-
phyromonas gingivalis and Treponema denticola) in sub-
gingival biolm samples taken from 60 subjects with
advanced periodontitis treated with scaling and root plan-
ing (SRP) alone or combined with 250 mg or 400 mg of
metronidazole (MTZ) + 500 mg of amoxicillin for 7 or
14 days, at 3 months post-treatment. Nine subgingival
biolm samples were taken from each subject at each time
point and were analyzed separately to determine their
content of the three red complex species. The percentage
of DNA probe counts for each species was determined at
each site, then averaged within a subject and then across
subjects in each group. The mean proportion of each
species was summed in order to determine the proportion
of the red complex. The signicance of differences
among groups was determined using KruskalWallis and
Dunns multiple comparison tests (different letters indi-
cate signicant differences between pairs of groups,
P < 0.05).
Systemic antibiotics in periodontal therapy
metronidazole) in comparison with the control
group (15.5%) (Fig. 13). No statistically signicant
differences were observed for the clinical and micro-
biological parameters evaluated between the two
groups taking 250 or 400 mg of metronidazole for
7 days or between those taking 250 or 400 mg of
metronidazole for 14 days. However, within the 14-
days antibiotic regimen, there was a tendency
toward better results for the higher-dose subgroup
(400 mg), mainly for the number of residual sites
with probing depth 5 mm post-therapy. No statisti-
cally signicant differences were observed among
the four antibiotic groups for the individual adverse
effects reported.
In summary, these short-term preliminary data
suggest that the duration of the metronidazole +
amoxicillin intake interferes with treatment success.
The adjunctive use of these antibiotics for 14 days,
irrespective of the metronidazole dosage, offers
short-term clinical and microbiological benets over
scaling and root planing alone, in the treatment of
advanced periodontitis. The added benets of the 7-
In which phase of the mechanical
treatment should the antibiotic be
prescribed?
B Two different questions related to the ideal time for
B systemic antibiotic use in periodontal treatment
remain unanswered: (i) should the antibiotic(s) be
administered during the active phase of therapy or on
re-evaluation (i.e. 3 or 6 months after active treat-
ment); and (ii) should the antibiotic(s) be adminis-
tered on the rst or last day of the scaling and root
MTZ 400 mg
14 days
planing procedure?
Let us focus on the rst question: Should the anti-
biotic (s) be administered during the active phase of
therapy or on re-evaluation?. Two previous investiga-
tions one retrospective study (96) and a randomized
clinical trial (55) have addressed this question, and
the results of both studies suggested greater clinical
benets when metronidazole + amoxicillin were
prescribed at the initial phase of therapy than in the
re-evaluation period. This statement is in line with
the notion, already strengthened in this article, that a
rapid and striking reduction in the subgingival
microbiota would be necessary in order to obtain the
most benecial recolonization possible of the
recently scaled pockets. Milder perturbations might
not be enough to change the highly stable climax
community of the mature biolm (194, 198). As
recolonization is partially achieved at 3 months
173

In summary, scaling and root planing leads to a
reduction in the levels and proportion of some peri-
odontal pathogens, but does not seem to modify the
composition of the subgingival biolm sufciently
for the new, benecial, bacterial community to
become established in a more denitive manner.
Therefore, other forms of therapies, such as antibi-
otics, have been used in conjunction with scaling
and root planing in order to potentiate the effects of
this treatment.
Local vs. systemic antibiotics and the
concern about the development of
bacterial resistance
Antibiotics can be used locally or systemically. Local
release of antimicrobial agents or antibiotics is nor-
mally carried out using bers, gels, chips or micro-
spheres (165). The greatest advantage of this usage is
avoidance of the side effects of drugs prescribed sys-
temically and a diminished chance of developing bac-
terial resistance to the medications. Therefore,
numerous studies have assessed the effects of locally
delivered antiseptics and antibiotics as adjuncts to
periodontal treatment (1, 7, 11, 51, 75, 78, 99, 143,
157, 158, 203). However, the overall outcomes of these
treatments were not found to be particularly promis-
ing (53, 56, 95, 135, 155, 176, 204), which might be
partially explained by some of the ecological concepts
discussed earlier in this article, such as the notion of
periodontal disease as an infection that affects the
entire mouth, including shallow sites, saliva, tongue
and cheeks. Thus, it was recognized that the use of
localized therapies restricted to a subset of deep sub-
gingival sites is particularly limited, and local antimi-
crobial therapy has more commonly been used
during the maintenance phase, for treating remaining
and isolated active pockets (82, 91). Conversely, sys-
temic antibiotics reach all the oral surfaces and uids,
in addition to having the potential to reach periodon-
tal pathogens that eventually invade the hosts tissues
(97, 172). The disadvantages of systemic antibiotics
over locally applied antibiotics include adverse drug
reactions (190), uncertain patient compliance (58,
114) and lower concentration of the drug at subgingi-
val sites (49). However, the severest criticism of the
indiscriminate use of systemic antibiotics is the devel-
opment of bacterial resistance. This phenomenon has
been of great concern in medicine and dentistry and
is considered one of the primary reasons for failure in
treating infectious diseases. Strains of subgingival
species that are resistant to commonly used antibiot-
ics can be isolated from subgingival biolm samples
Systemic antibiotics in periodontal therapy
(46, 13, 169, 210), although it is not clear whether
this is a result of selection by the antibiotic of resis-
tant organisms that already existed, or the creation
of new resistant species. Feres et al. (39, 41) deter-
mined the prevalence and proportions of metronida-
zole-, amoxicillin- and doxycycline-resistant bacteria
in the subgingival biolm and saliva samples of sub-
jects with chronic periodontitis, during and after the
administration of these agents. During antibiotic
administration, the proportion of resistant isolates
increased for all three tested antibiotics in both bio-
lm and saliva, falling to baseline levels by 90 days.
Most of the antibiotic-resistant species detected dur-
ing and after the administration of the drugs were
also detected before their administration, suggesting
that this transient increase in the proportion of resis-
tant isolates was most probably the result of an over-
growth of intrinsically resistant species present in
subgingival biolm before utilization of the antimi-
crobial agent than the emergence of new resistant
strains. Similar results were described by Rodrigues
et al. (169) for tetracycline and by Haffajee et al. (66)
for azithromycin. Overall examination of data from
these studies suggests that there was no compelling
evidence to indicate the emergence of antibiotic-
resistant strains of the taxa tested. However, it is con-
ceivable that antibiotic-resistant strains appeared
which could not be detected by the DNA probes used
in these investigations. Detecting the emergence of
antibiotic-resistant taxa, previously antibiotic sensi-
tive, in an ecosystem is not a trivial undertaking, but
clearly such events must occur otherwise there would
be no concern about the antibiotic resistance prob-
lem worldwide. Unfortunately, the frequency with
which such events occur during the typical use of
antibiotics in the treatment of periodontal patients is
still unknown. Thus, the recommendation of these
drugs in periodontology should follow the same pre-
cepts as those of medicine, which is, whenever their
real efcacy for the treatment of a certain infection
has been proved. This certainty may only be reached
by means of profound knowledge of the current sci-
entic literature about the use of these agents. The
main questions that should be asked in this regard
are: (i) Which drugs should be used? (ii) For which
cases? (iii) Which are the best protocols (doses and
durations)? (iv) In which phase of the mechanical
therapy (together or right after)? The following subi-
tems present and discuss the latest developments on
this topic in an effort to answer these questions and
to guide the clinicians decision on the use of sys-
temic antibiotics as adjuncts to periodontal treatment
in daily clinical practice.
139
Feres et al.
Which antibiotic(s) would provide the
most predictable results?
One of the rst reports on the effectiveness of
systemic antibiotics in periodontal treatment was
published in 1979. A 13-year-old patient with local-
ized juvenile periodontitis (at present denominated
localized aggressive periodontitis), who did not
respond to conventional therapy, was given a course
of tetracycline, which was followed by a marked clini-
cal and microbiological improvement (189). Several
subsequent clinical investigations showed that tetra-
cycline or its semisynthetic derivatives, such as doxy-
cycline and minocycline, were effective for the
treatment of localized aggressive periodontitis (110,
126, 127, 150, 151). Many studies focused on the elim-
ination or reduction of A. actinomycetemcomitans,
which was, for a long time, highlighted as the sole
pathogen associated with aggressive periodontitis in
young individuals and does not respond well to
mechanical debridement (12, 144, 149, 187, 222). Sub-
sequently, almost all available antibiotics have been
tested for use in the treatment of chronic or aggres-
sive periodontitis, such as amoxicillin (40, 168, 170),
azithromycin (29, 34, 47, 60, 61, 66, 72, 77, 129,
152, 177, 192, 220), clindamycin (183), doxycycline
(10, 183, 215), metronidazole (14, 15, 40, 42, 66, 72,
111, 130, 170, 183, 184, 215), tetracycline (163) and a
combination of metronidazole and amoxicillin (2, 10,
16, 18, 19, 33, 42, 50, 55, 59, 85, 95, 122, 123, 130, 136,
138, 139, 141, 160, 166, 170, 184, 211, 212, 214, 215,
221). The experimental designs and main ndings of
the randomized clinical trials on the effects of sys-
temic antibiotics in the periodontal treatment pub-
lished from January 2001 to August 2012 are
presented in Tables 4 and 5. Table 4 summarizes the
studies conducted in Latin America (Brazil and Chile)
and Table 5 summarizes the studies conducted in
North America (the USA), Europe (Sweden, the UK,
Spain, Switzerland, Italy, the Netherlands, Germany,
Turkey and Greece) and Asia (Japan, Iran and China).
The rst two systematic reviews with meta-analysis
that directly compared the effects of different adjunc-
tive systemic antibiotics in the treatment of periodon-
titis were published in the early 2000s and were
unable to assign superiority to a certain antibiotic or
combination of drugs owing to the limited number of
studies using each of the antibiotic protocols and the
substantial differences among the study designs (67,
87). However, the overall evaluation of the random-
ized clinical trials published in the last decade
(Tables 4 and 5) suggests that the most promising
drugs for the treatment of periodontal diseases are
140
metronidazole or the combination of metronidazole
+ amoxicillin, a protocol originally proposed by Win-
kelhoff and coworkers for the treatment of A. actino-
mycetemcomitans-associated periodontitis (211).
With the aim of directly comparing these two antibi-
otic protocols, we conducted the following analysis in
a group of subjects with either aggressive or chronic
periodontitis. The data are a compilation and exten-
sion of those described by Mestnik et al. (138, 139)
and Feres et al. (42), and the results are presented in
Tables 68 and Figs 4 and 5. After a baseline-moni-
toring visit, subjects received quadrant scaling and
root planing, alone or combined with 400 mg of met-
ronidazole or with 400 mg of metronidazole and
500 mg of amoxicillin. The antibiotics were adminis-
tered three times daily for 14 days and started at the
same time as the mechanical therapy. Subjects in the
control and metronidazole groups received placebo.
Clinical and microbiological monitoring, as well as
periodontal maintenance, were performed at
3 months, 6 months and 1 year post-treatments. The
mean baseline probing depth and clinical attachment
level were, respectively, 3.9 mm and 4.3 mm for the
scaling and root planing group, 3.7 mm and 4.2 mm
for the metronidazole group and 3.9 mm and 4.3 mm
for the metronidazole + amoxicillin group. At base-
line, no statistically signicant differences among
groups were observed for any clinical parameter eval-
uated and for the number of subjects reporting
adverse events, or between the two antibiotic groups
for the individual adverse effects reported (P > 0.05,
data not shown). Table 6 presents the mean number
of sites with probing depth 5 mm, 6 mm and
7 mm at all time-points. Even though the number of
deep sites did not differ among the three groups at
baseline, the two antibiotic-treated groups presented
statistically signicantly fewer of these three catego-
ries of residual sites at all follow-up appointments.
Interestingly, subjects taking antibiotics continued to
show some further reduction in deep sites from
3 months to 1 year post-treatment, whereas this
improvement was less marked for subjects treated
with scaling and root planing only, especially for sites
with probing depth 5 mm. Clear difference was
observed among groups for the mean number of sites
with probing depth 5 mm at 1 year post-treatment.
Subjects receiving scaling and root planing only still
had a mean of 18 of these residual sites, compared
with 8 and 5.3 in the metronidazole and metronida-
zole+amoxicillin groups, respectively. Table 7 pre-
sents the percentage of subjects reaching the clinical
endpoint for treatment. All subjects included in this
analysis had at least nine sites with probing depth
 Table 4. Randomized clinical trials testing the effects of systemic antibiotics on the periodontal treatment conducted in Latin America (20012012)

Country and Duration Placebo Antibiotic and dose Total Age (years) No. of Initial mean Disease Antibiotic therapy
References (Yes/No) population/ smokers probing (duration/moment)
no. of groups depth (mm)

(a) Experimental designs

Brazil

Rodrigues et al. 3 months No Amoxicillin/ 30/2 Not stated 0 2.73.2 Chronic Twice daily for 14 days,
(168) Clavulanic acid periodontitis starting 24 hours before
875 mg the rst scaling and root
planing session
Carvalho et al. 3 months Yes Metronidazole 44/4 45  6 12 3.74.1 Chronic Twice daily for 10 days,
(14, 15) 400 mg periodontitis starting after scaling and
root planing
Haas et al. (60, 1 year Yes Azithromycin 25/2 1326 5 4.74.8 Aggressive Once daily for 3 days,
61) 500 mg periodontitis starting at the rst scaling
and root planing session
Matarazzo et al. 3 months Yes Metronidazole 43/3 41.8  7.1 43 3.74.0 Chronic Three times daily for
(130) 400 mg Amoxicillin periodontitis 14 days, starting at the
500 mg rst scaling and root
planing session
Ribeiro et al. (166) 6 months Yes Metronidazole 25/2 3066 0 6.26.4 Chronic Three times daily for
250 mg Amoxicillin periodontitis 7 days, starting at the rst
375 mg scaling and root planing
session
Mestnik et al. 3 months Yes Metronidazole 30/2 27.2  3.7 0 4.14.3 Aggressive Three times daily for
(138, 139) 1 year 400 mg Amoxicillin periodontitis 14 days, starting at the
500 mg rst scaling and root
planing session
Sampaio et al. 1 year Yes Azithromycin 40/2 44.1  6.2 10 4.85.0 Chronic Once daily for 5 days,
(177) 500 mg periodontitis starting after scaling and
root planing
Silva et al. (184) 3 months Yes Metronidazole 51/3 45.5  9.6 0 3.63.8 Chronic Three times daily for
400 mg Amoxicillin periodontitis 14 days, starting at the
500 mg rst scaling and root
planing session

141
Systemic antibiotics in periodontal therapy
 Table 4. (Continued)

142
Country and Duration Placebo Antibiotic and dose Total Age (years) No. of Initial mean Disease Antibiotic therapy
References (Yes/No) population/ smokers probing (duration/moment)
Feres et al.

no. of groups depth (mm)

Varela et al. (212); 6 months Yes Metronidazole 35/2 32.5  4.5 4 4.24.3 Aggressive Three times daily for
Heller et al. (85) 250 mg Amoxicillin periodontitis 10 days Starting at the
500 mg last session
Full-mouth ultrasonic
debridment
Casarin et al. (16) 6 months Yes Metronidazole 24/2 28.5  6.1 0 6.46.6 Aggressive Three times daily for
250 mg Amoxicillin periodontitis 7 days, starting at the rst
375 mg scaling and root planing
session
Feres et al. (42) 1 year Yes Metronidazole 120/3 44.8  8.4 0 3.73.9 Chronic Three times daily for
400 mg Amoxicillin periodontitis 14 days, starting at the
500 mg rst scaling and root
planing session
Chile

Lo
 pez et al. (123) 1 year Yes Metronidazole 22/2 3868 9 2.42.8 Chronic Three times daily for
250 mg Amoxicillin periodontitis 7 days, starting at the rst
500 mg scaling and root planing
visit
Lo
 pez et al. (122) 1 year Yes Metronidazole 165/2 3565 46 Not stated Chronic Three times daily for
250 mg Amoxicillin periodontitis 7 days, starting 1 week
500 mg before scaling and root
planing

Country and Treatment Principal clinical ndings Principal microbiological

References ndings (method)
Test Control

(b) Main ndings

Brazil

Rodrigues et al. (168) Full-mouth scaling and root planing
(two sessions) + amoxicillin/
clavulanic acid
Full-mouth scaling and No difference between groups in full-mouth No
root planing mean probing depth (full-mouth scaling and
root planing+amoxicillin/clavulanic acid,
0.8  0.6 mm; full-mouth scaling and root
planing, 0.9  0.4 mm) (P > 0.05)
 Table 4. (Continued)

Country and Treatment Principal clinical ndings Principal microbiological

References ndings (method)
Test Control

Carvalho et al. (14, 15) Scaling and root
planing+metronidazole
Scaling and root
planing+supragingival
scaling+placebo
Scaling and root
planing+supragingival
scaling+metronidazole
Haas et al. (60, 61) Scaling and root
planing+azithromycin
Matarazzo et al. (130) Scaling and root
planing+metronidazole
Scaling and root
planing+metronidazole+amoxicillin
Scaling and root Groups treated with metronidazole (with or
planing+placebo without supragingival scaling) showed greater
mean probing depth reduction in sites with
initial probing depth 7 mm than the other
groups (P < 0.05). No difference between
groups in clinical attachment gain (P > 0.05) at scaling+metronidazole groups
3 months
Scaling and root No difference between groups in mean probing-
planing+placebo depth reduction (azithromycin, 3.5  0.2 mm;
scaling and root planing, 2.7  0.5 mm) and
clinical attachment gain (azithromycin,
2.0  0.2 mm; scaling and root planing,
1.3  0.3 mm) (P > 0.05) in sites with initial
probing depth 7 mm at 1 year. Test group
showed a higher mean percentage of teeth
with clinical attachment gain 1 mm
(azithromycin: 81.3  3.3 mm; scaling and
root planing: 63.6  7.3 mm) (P < 0.05)
Scaling and root The metronidazole+amoxicillin group showed The greatest reduction in the
planing+placebo greater full-mouth mean probing depth
reduction (1.0 mm) and clinical attachment
gain (0.9 mm) than the metronidazole
(probing depth, 0.8 mm; clinical attachment,
0.6 mm) and control (probing depth, 0.6 mm;
clinical attachment, 0.5 mm) groups (P < 0.05) control group (from 33% to
at 3 months
Counts of Porphyromonas
gingivalis, Tannerella forsythia
and Treponema denticola were
only reduced in supragingival
scaling and supragingival
at 3 months (P < 0.05)
(checkerboard DNADNA
hybridization)
Levels of most bacterial species
decreased in both groups with
a similar pattern at 1 year
(P > 0.05) (checkerboard DNA
DNA hybridization)
red complex occurred in
metronidazole+amoxicillin
(from 32% to 2%) and
metronidazole (from 25% to
4%) groups, followed by the
8%) at 3 months
(checkerboard DNADNA
hybridization)

143
Systemic antibiotics in periodontal therapy
 Table 4. (Continued)

144
Country and Treatment Principal clinical ndings Principal microbiological
References ndings (method)
Feres et al.

Test Control

Ribeiro et al. (166) One session of full-mouth ultrasonic
debridment+metronidazole+
amoxicillin
Mestnik et al. (138, Scaling and root
139) planing+metronidazole+amoxicillin
Sampaio et al. (177) Scaling and root
planing+azithromycin
One session of full-mouth No difference between groups in mean probing Both therapies were
ultrasonic depth reduction in sites with initial probing comparable (P > 0.05) in
debridment+placebo depth 7 mm (metronidazole, 3.9  0.9 mm; lowering periodontal
Full-mouth ultrasonic debridment: pathogens at 6 months
3.4  0.7 mm) (P > 0.05). Test group showed a (real-time PCR)
higher mean percentage of sites with clinical
attachment gain of 2 mm (metronidazole,
58.0%; full-mouth ultrasonic debridment,
43.5%) (P < 0.05) at 6 months
Scaling and root The test group showed greater mean probing The most benecial changes
planing+placebo depth reduction (metronidazole+amoxicillin, were observed in the
4.2  1.4 mm; scaling and root planing, metronidazole+amoxicillin
2.8  1.1 mm) and clinical attachment gain group, which showed the
(metronidazole+amoxicillin, 3.4  1.2 mm; lowest proportions of red
scaling and root planing, 2.3  1.1 mm) complex species as well as a
(P < 0.05) in sites with initial probing depth 7 signicant decrease in the
mm at 1 year. Test group showed a lower orange complex at 3 months.
mean number of sites with probing depth Results from 1 year data are
5 mm than the control group at 1 year not yet published
(6.4  7.2 and 23.1  13.1 sites, respectively) (checkerboard DNADNA
(P < 0.05) hybridization)
Scaling and root No difference between groups in mean probing The counts and proportions of
planing+placebo depth reduction (azithromycin, 3.4  1.7 mm; some periodontal pathogens
scaling and root planing, 3.8  1.9 mm) and were equally reduced in both
clinical attachment gain (azithromycin, groups. The proportions of red
2.7  1.7 mm; scaling and root planing, complex species were
2.3  1.7 mm) (P > 0.05) in sites with initial relatively high in both groups
probing depth 7 mm at 1 year. The mean at 1 year (checkerboard
number of remaining sites with probing depth DNADNA hybridization)
5 mm was high in both groups at 1 year
(17)
 Table 4. (Continued)
Country and Treatment
References
Test
Silva et al. (184) Scaling and root
planing+metronidazole;
Scaling and root
planing+metronidazole+amoxicillin
Varela et al. (212); Phase I: Full-mouth ultrasonic
Heller et al. (85) debridement (irrigation of pockets,
gargling and brushing the tongue
chlorhexidine 0.2%,
45 days+metronidazole+amoxicillin
Phase II (started a week after Phase
I): scaling and root planing
+irrigation of pockets
Casarin et al. (16) One session of full-mouth ultrasonic
debridment+metronidazole+
amoxicillin
145
Principal clinical ndings Principal microbiological
ndings (method)
Control
Scaling and root Both test groups showed greater mean probing Scaling and root planing+
planing+placebo depth reduction (metronidazole+amoxicillin, metronidazole+amoxicillin
3.6  0.6 mm; metronidazole, 3.3  1.0 mm; was the only treatment that
scaling and root planing, 2.3  1.1 mm) and signicantly reduced the levels
clinical attachment gain and proportions of all red
(metronidazole+amoxicillin, 3.0  0.7 mm; complex pathogens and
metronidazole, 2.7  1.3 mm; scaling and root elicited a signicant greater
planing, 2.1  1.0 mm) (P < 0.05) in sites with benecial change in the
initial probing depth 7 mm at 3 months. The microbial prole at 3 months
metronidazole+amoxicillin group showed a (checkerboard DNADNA
lower mean number of sites (mean=5.3) with hybridization)
probing depth 5 mm than the control group
(mean=13.3) (P < 0.05) at 3 months
Phase I: equal to the test No difference between groups in full-mouth Both therapies were
group+placebo mean probing depth reduction comparable in lowering
Phase II: equal to the test (metronidazole+amoxicillin, 1.5 mm; periodontal pathogens at
group full-mouth ultrasonic debridment, 0.9 mm) 6 months (checkerboard
(P > 0.05) and clinical attachment gain DNADNA hybridization)
(metronidazole+amoxicillin, 1.2 mm;
full-mouth ultrasonic debridement, 0.7 mm)
(P > 0.05) at 6 months. Four-hundred and
twenty-four sites in the control group and 263
sites in the test group (P < 0.05) did not
respond to treatment and were
re-instrumented at 3 months
One session of Full-mouth The test group showed greater mean probing Both therapies were
ultrasonic depth reduction in sites with initial probing comparable (P > 0.05) in
debridment+placebo depth 7 mm (4.1  1.4 mm) than the control lowering periodontal
group (3.3  0.6 mm) (P < 0.05) at 6 months. pathogens at 6 months (real
No additional benets in clinical attachment time PCR)
gain were observed in the test group
Systemic antibiotics in periodontal therapy
 Table 4. (Continued)

146
Country and Treatment Principal clinical ndings Principal microbiological
References ndings (method)
Feres et al.

Test Control

Feres et al.. (42) Scaling and root Scaling and root Test groups showed greater mean probing- No
planing+metronidazole; planing+placebo depth reduction (metronidazole+amoxicillin,
scaling and root 4.1  0.7 mm; metronidazole, 3.9  0.9 mm;
planing+metronidazole+amoxicillin scaling and root planing, 3.1  1.4 mm) and
clinical attachment gain
(metronidazole+amoxicillin, 3.4  0.8 mm;
metronidazole, 3.1  1.1 mm; scaling and root
planing, 2.6  1.2 mm) (P < 0.05) in sites with
initial probing depth 7 mm at 1 year. Both
test groups showed a lower mean number of
sites with probing depth 5 mm than the
control group at 1 year
(metronidazole+amoxicillin, 4.7  6.0 sites;
metronidazole, 6.3  7.3 sites; scaling and root
planing, 16.1  15.6 sites) (P < 0.05)
Chile

Lo
 pez et al. (123) Supragingival Supragingival No difference between groups in full-mouth There were no statistically
scaling+metronidazole+amoxicillin scaling+scaling and root mean probing depth signicant differences at any
planing+placebo (metronidazole+amoxicillin, 0.8 mm; scaling time point between groups
and root planing, 0.5 mm) and clinical (P > 0.05) (checkerboard DNA
attachment gain (metronidazole+amoxicillin, DNA hybridization).
0.3 mm; full-mouth ultrasonic debridment,
0.17 mm) (P > 0.05) at 1 year. The mean
percentage of sites with clinical attachment
gain >2 mm was higher in the test group
(3.8%) than in the control group (1.1%), but
the difference was not statistically signicant
Lo
 pez et al. (122) Supragingival scaling+scaling and Supragingival The test group showed a lower mean No
root planing+metronidazole + scaling+placebo percentage of sites with probing depth 4 mm
amoxicillin (P < 0.05) at 1 year
 Table 5. Randomized clinical trials testing the effects of systemic antibiotics in the periodontal treatment conducted in North America, Europe and Asia

Geographic Duration Placebo Antibiotic/dose Total Age (years) No. of Initial mean Disease Antibiotic therapy (duration
Region/ (Yes/No) population/ smokers probing and moment)
References no. of groups depth (mm)

(a) Experimental designs

North America

Feres et al. 1 year No Metronidazole 250 mg 17/2 44  13 Not stated 3.23.4 Chronic Three times daily for 14 days.
(40) Amoxicillin 500 mg periodontitis Starting at the rst scaling
and root planing session
Mascarenhas 6 months No Azithromycin 250 mg 31/2 46  10 31 3.54.2 Chronic Once daily for 5 days Starting
et al. (129) periodontitis at the second scaling and
root planing session
Haffajee et al. 1 year No Azithromycin 500 mg 92/4 45  12 9 2.93.3 Chronic Azithromycin, once daily for
(66, 72) Metronidazole periodontitis 3 days
250 mg Metronidazole, three times
Sub-antibacterial dose daily for 14 days
doxycyline 20 mg Sub-antibacterial dose
doxycyline, twice daily for
12 weeks
Starting at the rst scaling
and root planing session
Dastoor et al. 6 months Yes Azithromycin 500 mg 30/2 51  8.1 30 2.83.2 Chronic Once daily for 3 days
(29) periodontitis Starting after surgery

Goodson et al. 2 years No Metronidazole 250 mg 187/8 >20 years 75 5.96.2 Chronic Metronidazole, three times
(50) Amoxicillin 500 mg periodontitis daily for 14 days
Local tetracycline Amoxicillin, twice daily for
delivery ber 14 days
(1.7 mg/tooth) Starting at the rst scaling
and root planing visit
Local tetracycline delivery
ber after scaling and root
planing
Europe

Winkel et al. 6 months Yes Metronidazole 250 mg 49/2 2863 32 4.4 Chronic Three times daily for 7 days
(214) Amoxicillin 350 mg periodontitis Starting 6 weeks after scaling
and root planing

147
Systemic antibiotics in periodontal therapy
 Table 5. (Continued)

148
Geographic Duration Placebo Antibiotic/dose Total Age (years) No. of Initial mean Disease Antibiotic therapy (duration
Region/ (Yes/No) population/ smokers probing and moment)
Feres et al.

References no. of groups depth (mm)

Ramberg et al. 13 years No Tetracycline 250 mg 115/2 2366 66 3.94.2 Advanced Four times daily for 21 days
(163) periodontitis Starting before scaling and
root planing
Sigusch et al. 2 years No Doxycycline 200 mg 48/4 32.4 0 5.55.9 Rapidly Doxycycline, once daily;
(183) Metronidazole 500 mg progressive metronidazole, twice daily;
Clindamycin 150 mg periodontitis and
clindamycin, four times a
day for 8 days
Starting after full-mouth
scaling and root planing
Smith et al. 22 weeks Yes Azithromycin 44/2 42.6  8.5 10 3.23.4 Chronic Once daily for 3 days Staring
(192) 500 mg periodontitis at the last week
of scaling and root planing
Rooney et al. 6 months Yes Metronidazole 200 mg 66/4 2045 0 Just per Chronic Three times daily for 7 days
(170) Amoxicillin 250 mg categories periodontitis Starting after scaling and
of sites root planing
Ehmke et al. 2 years No Metronidazole 250 mg 35/2 51.1  10.7 3 Just per Chronic Three times daily for 8 days
(33) Amoxicillin 375 mg categories periodontitis Starting after scaling and
of sites root planing
Guerrero et al. 6 months Yes Metronidazole 500 mg 41/2 1635 9 4.1 Aggressive Three times daily for 7 days
(59) Amoxicillin 500 mg periodontitis Starting at the rst scaling
and root planing visit
Mombeli et al. 1 year Yes Metronidazole 250 mg 16/2 2565 6 6.87.7 Chronic Three times daily for 7 days
(142) Amoxicillin 375 mg periodontitis Starting after scaling and
root planing
Xajigeorgiou 6 months No Metronidazole 500 mg 43/4 2249 15 4.24.7 Aggressive Metronidazole, amoxicillin,
et al. (215) Amoxicillin 500 mg periodontitis three times daily for 7 days
doxycycline 100 mg Doxycycline, once daily for
14 days
Starting after scaling and
root planing
Cionca et al. 6 months Yes Metronidazole 500 mg 51/2 2570 16 4.34.4 Chronic Three times daily for 7 days
(18, 19) Amoxicillin 375 mg periodontitis Starting after scaling and
root planing
 Table 5. (Continued)

Geographic Duration Placebo Antibiotic/dose Total Age (years) No. of Initial mean Disease Antibiotic therapy (duration
Region/ (Yes/No) population/ smokers probing and moment)
References no. of groups depth (mm)

Yek et al. (221) 6 months No Metronidazole 500 mg 28/2 1545 7 Just per Aggressive Three times daily for 7 days
Amoxicillin 500 mg categories periodontitis Starting at the rst scaling
of sites and root planing session
Oteo et al. 6 months Yes Azithromycin 500 mg 29/2 3665 14 2.82.9 Chronic Once daily for 7 days
(152) periodontitis Starting after scaling and
root planing
Baltacioglu 2 months No Metronidazole 250 mg 38/3 1840 15 4.9 Aggressive Metronidazole, amoxicillin,
et al. (10) Amoxicillin 250 mg periodontitis three times daily for 10 days
doxycycline 100 mg Doxycycline, once daily for
14 days
Starting after scaling and
root planing
Aimetti et al. 6 months Yes Metronidazole 500 mg 39/2 35.5  2.9 0 4.34.5 Aggressive Three times daily for 7 days
(2) Amoxicillin 500 mg periodontitis Starting at the rst scaling
and root planing session
Han et al. (77) 6 months Yes Azithromycin 500 mg 28/2 3554 13 3.84.0 Chronic Once daily for 3 days
periodontitis Starting after scaling and
root planing
Emingil et al. 6 months Yes Azithromycin 500 mg 32/2 1838 13 3.84.1 Aggressive Once daily for 3 days
(34) periodontitis Starting after scaling and
root planing
Asia

Gomi et al. 25 weeks No Azithromycin 500 mg 34/2 48.2  11.5 0 4.5 Chronic Once daily for 3 days
(47) periodontitis Starting before scaling and
root planing

149
Systemic antibiotics in periodontal therapy
 Table 5. (Continued)

150
Geographic Duration Placebo Antibiotic/dose Total Age (years) No. of Initial mean Disease Antibiotic therapy (duration
Region/ (Yes/No) population/ smokers probing and moment)
Feres et al.

References no. of groups depth (mm)

Moentaghavi 8 weeks Yes Metronidazole 250 mg 50/2 34.4  8.2 0 5.65.8 Chronic Three times daily for 7 days
et al. (141) Amoxicillin 500 mg periodontitis Starting at the rst scaling
and root planing session
Yashima et al. 1 year No Azithromycin 500 mg 30/3 51  12.6 0 5.1 Chronic Once daily for 3 days
(220) periodontitis Starting before scaling and
root planing

Geographic Treatment Principal clinical ndings Principal microbiological ndings

Region/ (method)
References Test Control

(b) Main ndings

North America

Feres et al. (39) Scaling and root planing+amoxicillin
scaling and root planing+metronidazole
Mascarenhas Scaling and root planing+azithromycin
et al. (129)
Haffajee et al. Scaling and root planing+azithromycin
(66, 72) Scaling and root planing+metronidazole
Scaling and root planing+sub-
antibacterial dose doxycyline
No difference between groups in full- Levels and proportions of Tannerella
mouth mean probing depth (amoxicillin, forsythia, Porphyromonas gingivalis and
0.4 mm; metronidazole, 0.6 mm), and Treponema denticola were reduced
clinical attachment gain (amoxicillin, during antibiotic administration and
0.5 mm; metronidazole, 0.3 mm were lower than baseline levels at 1 year
(P > 0.05) at 1 year (P < 0.001). Amoxicillin lowered the
proportions of Actinomyces species
(checkerboard DNADNA hybridization)
Scaling and root The test group showed greater mean There was a 3.35% and 33.32% reduction
planing probing depth reduction (azithromycin, on BANA-positive sites (six sites per
3.5 mm; scaling and root planing, subject) for the scaling and root planing
2.0 mm), and clinical attachment gain and azithromycin groups, respectively
(azithromycin, 2.6 mm; and scaling and (P < 0.05) (BANA Test)
root planing, 1.3 mm (P < 0.05) in sites
with initial PD 7 mm at 6 months
Scaling and root Azithromycin and metronidazole groups All treatments reduced counts of red
planing showed greater mean probing depth complex species at 1 year. No major
reduction and clinical attachment gain in differences were detected among
sites with initial probing depth 7 mm treatment groups at 1 year (checkerboard
than the other groups (P < 0.05) at 1 year DNADNA hybridization)
 Table 5. (Continued)

Geographic Treatment Principal clinical ndings Principal microbiological ndings

Region/ (method)
References Test Control

Dastoor et al. Scaling and root planing+periodontal Scaling and root Control group showed greater mean Both treatments reduced the mean BANA
(29) surgery+azithromycin planing+periodontal probing depth reduction in sites with scores at 2 weeks after surgery (0.80 and
surgery+ initial probing depth 7 mm for the 0.77 for periodontal
placebo surgically (azithromycin+periodontal surgery+azithromycin and periodontal
surgery, 2.8 mm; periodontal surgery, surgery groups, respectively). At
3.8 mm, P < 0.05) and nonsurgically 6 months, BANA scores in both groups
(azithromycin+periodontal surgery, returned to baseline levels (BANA Test)
2.0 mm; periodontal surgery, 2.8 mm,
P < 0.05) treated sites at 6 months
Goodson et al. Scaling and root planing+local tetracycline Scaling and root Test groups receiving No
(50) delivery planing metronidazole+amoxicillin showed
Scaling and root planing+systemic 0.5 mm more mean probing depth
metronidazole+amoxicillin reduction and clinical attachment gain
Scaling and root planing+systemic (P < 0.05), than control group at 2 years
metronidazole+amoxicillin+local
tetracycline delivery
Scaling and root planing+periodontal
surgery
Scaling and root planing+local
tetracycline delivery+periodontal surgery
Scaling and root planing+systemic
metronidazole+amoxicillin+periodontal
surgery
Scaling and root planing+systemic
metronidazole+amoxicillin+local
tetracycline delivery+periodontal surgery
Europe

Winkel et al. Scaling and root Scaling and root The test group showed greater mean
(214) planing+metronidazole+amoxicillin planing+placebo probing depth reduction
(metronidazole+amoxicillin, 3.2 mm;
scaling and root planing, 2.5 mm), and
clinical attachment gain
(metronidazole+amoxicillin, 2.0 mm;
scaling and root planing, 1.5 mm)
(P < 0.05) in sites with initial PD >7 mm
at 6 months
No statistically signicant decrease was
observed in the number of subjects
colonized by any of the tested species in
the scaling and root planing group
(P > 0.05). In the
metronidazole+amoxicillin group the
number of subjects colonized by P.
gingivalis, T. forsythia and Prevotella
intermedia showed a signicant decrease
at 6 months (P < 0.05) (culture)

151
Systemic antibiotics in periodontal therapy
152
Table 5. (Continued)
Feres et al.

Geographic Treatment Principal clinical ndings Principal microbiological ndings

Region/ (method)
References Test Control

Ramberg et al. Scaling and root planing+tetracycline Scaling and root No difference between groups in full- No
(163) planing mouth mean probing depth
(tetracycline, 1.0  0.8 mm; scaling and
root planing, 0.7  0.7 mm) (P > 0.05),
and the test group showed greater mean
clinical attachment gain (tetracycline,
0.5  0.6 mm; scaling and root planing,
0.2  0.5 mm) (P < 0.05) at 1 year. This
benet was not maintained at 3, 5 and
13 years
Sigusch et al. Scaling and root planing+ doxycycline Scaling and root Metronidazole and clindamycin groups The mean number of colon-forming units
(183) Scaling and root planing+metronidazole planing showed greater mean probing depth for P. gingivalis and Actinobacillus
Scaling and root planing+clindamycin reduction (4.8 mm for both groups) and actinomycetemcomitans was reduced in
clinical attachment gain (3.4 mm and the metronidazole and clindamycin
2.9 mm, respectively) in sites with initial groups (P < 0.05) at 2 years
probing depth 7 mm than the
doxycycline (probing depth reduction,
2.0 mm; clinical attachment gain,
1.4 mm) and control groups (probing
depth reduction, 1.2 mm; clinical
attachment gain, 0.5 mm) (P < 0.05) at
2 years
Smith et al. Scaling and root planing+azithromycin Scaling and root The test group showed greater mean No
(192) planing+placebo probing depth reduction in sites with
initial probing depth 6 mm and in the
full-mouth mean probing depth at
22 weeks
Rooney et al. Scaling and root Scaling and root The test group showed better clinical No statistically signicant differences were
(170) planing+amoxicillin+metronidazole planing+placebo results than the control group. The observed among groups at 6 months
Scaling and root greatest improvement in mean (P > 0.05) (Culture)
planing+metronidazole+placebo percentage of sites 6 mm was observed
Scaling and root in the amoxicillin+metronidazole group
planing+amoxicillin+placebo at 6 months
 Table 5. (Continued)

Geographic Treatment Principal clinical ndings Principal microbiological ndings

Region/ (method)
References Test Control

Ehmke et al. Scaling and root planing+metronidazole+
(33) amoxicillin+chlorhexidine
Guerrero et al. Full-mouth scaling and root
(59) planing+metronidazole+amoxicillin
Mombeli et al. Full-mouth scaling and root
(142) planing+Emdogain+metronidazole+
amoxicillin
Xajigeorgiou Scaling and root planing+metronidazole
et al. (215) Scaling and root planing+doxycycline
Scaling and root planing+
metronidazole+Amoxicillin
Scaling and root The test group showed greater mean The prevalence of A.
planing clinical attachment gain in sites with actinomycetencomitans (up to
initial probing depth 7 mm 18 months) and P. gingivalis (up to
(metronidazole+amoxicillin+ 3 months) were lower and of Eikenella
chlorhexidine, 1.7  0.3 mm; scaling and corrodens (at 10 days) were higher
root planing, 0.3  0.3 mm) (P < 0.05) at (P < 0.05) in the test group compared
2 years. with the control group. (PCR and dot-blot
hybridization)
Full-mouth scaling and The test group showed greater mean No
root planing+placebo probing depth reduction
(metronidazole+amoxicillin, 3.1 mm;
scaling and root planing, 1.8 mm) and
clinical attachment gain
(metronidazole+amoxicillin, 2.3 mm;
scaling and root planing, 1.3  0.6 mm)
(P < 0.05) in sites with intial PD 7 mm at
6 months.
Full-mouth scaling and The test group showed greater mean No
root planing+ probing depth reduction (scaling and
Emdogain+placebo root planing+Emdogain+metronidazole+
amoxicillin, 3.0  2.1 mm; scaling and
root planing+Emdogain, 1.6  1.4 mm)
and clinical attachment gain
(metronidazole+amoxicillin,
2.3  3.5 mm; Emdogain, 0.4  3.8 mm)
(P < 0.05) at 1 year
Scaling and root Metronidazole+amoxicillin and Metronidazole+amoxicillin was the only
planing metronidazole groups showed greater treatment that caused a reduction in the
reduction in the mean proportion of sites levels of A. actinomycetemcomitans and
with probing depth 7 mm (80% and of the three red complex species at
87.8%, respectively) than the control 6 months (P < 0.05) (checkerboard DNA
group (scaling and root planing, 57.7%) at DNA hybridization)
6 months (P < 0.05). No differences were
observed between doxycycline and
control groups (P > 0.05)

153
Systemic antibiotics in periodontal therapy
 Table 5. (Continued)

154
Geographic Treatment Principal clinical ndings Principal microbiological ndings
Region/ (method)
Feres et al.

References Test Control

Cionca et al. (18, Scaling and root
19) planing+metronidazole+amoxicillin
Yek et al. (221) Scaling and root
planing+metronidazole+amoxicillin
Oteo et al. (152) Scaling and root planing+azithromycin
Baltacioglu et al. Full-mouth scaling and root
(10) planing+doxycycline
Full-mouth scaling and root
planing+metronidazole+amoxicillin
Scaling and root The test group showed a lower mean No differences for total bacterial load were
planing+placebo number of sites with probing depth observed between groups (P > 0.05).
5 mm+bleeding on probing (0.4  0.8 P. gingivalis, Fusobacterium nucleatum
sites) than the control group (3.0  4.3 spp. and T. forsythia counts were lower in
sites, P < 0.05) at 6 months the test group than in the control
(P < 0.05) at 6 months (real-time PCR)
Scaling and root The test group showed greater mean T. denticola showed a steady decrease only
planing reduction in the mean proportion of sites in the test group. T. forsythia decreased
with probing depth 7 mm (P < 0.05) at in both groups, but at 6 months it was
6 months eliminated from the sampled sites only in
test group (PCR)
Scaling and root The test group showed a greater reduction The frequency of detection of P. gingivalis
planing+placebo in full-mouth mean probing depth and T. forsythia decreased at 6 months in
(azithromycin, 0.80 mm; scaling and root the test group (P < 0.05) (Culture)
planing, 0.34 mm) and clinical
attachment gain (azithromycin, 0.76 mm;
and scaling and root planing, 0.29 mm)
(P < 0.05) at 6 months
Full-mouth scaling and The metronidazole+amoxicillin group No
root planing showed a lower mean proportion of sites
with probing depth 7 mm (8.6  4.0%)
than the doxycycline (13.6  6.8%) and
control groups (scaling and root planing,
22.2  6.5%) at 2 months (P < 0.05).
Mean probing depth and clinical
attachment level were signicantly lower
in the metronidazole+amoxicillin group
(3.3  0.4 mm) than the doxycycline
(3.9  0.3 mm) and control groups
(4.2  0.2 mm) at 2 months (P < 0.05)
 Table 5. (Continued)

Geographic Treatment Principal clinical ndings Principal microbiological ndings

Region/ (method)
References Test Control

Aimetti et al. (2) One session of full-mouth scaling and root One session of full- The test group showed a greater mean
planing+metronidazole+amoxicillin mouth scaling and probing depth reduction (metronidazole+
root planing+placebo amoxicillin, 3.1  0.6 mm; scaling and
root planing, 2.4  0.7 mm) and clinical
attachment gain (metronidazole+
amoxicillin, 3.0  0.7 mm; scaling and
root planing, 2.0  0.8 mm) (P < 0.05) in
sites with intial PD 7 mm at 6 months.
The mean percentage of sites with
probing depth 5 mm was lower in the
test group (17.7%) than the control group
(28.4%) at 6 months (P < 0.05)
Han et al. (77) Scaling and root planing+azithromycin Scaling and root No difference between groups in mean
planing+placebo probing depth reduction (azithromycin,
4.9  1.1 mm; scaling and root planing,
4.5  0.5 mm) and clinical attachment
gain (azithromycin, 2.3  3.1 mm;
scaling and root planing, 0.6  0.5 mm)
(P > 0.05) in sites with initial PD 7 mm
at 6 months
Emingil et al. Scaling and root planing+azithromycin Scaling and root No difference between groups in mean
(34) planing+placebo probing depth reduction and clinical
attachment gain (P > 0.05) in sites with
initial PD 7 mm at 6 months
Asia
The test group showed lower prevalences
of A. actinomycetemcomitans, T.
denticola, and T. forsythia compared with
the control group (P < 0.05) at 6 months
(PCR)
Both groups showed similar mean
reduction in levels of A.
actinomycetemcomitans, P. gingivalis,
T. forsythia , P. intermedia and
F.nucleatum at 6 moths (P > 0.05) (real-
time PCR)
Both groups showed similar levels of P.
gingivalis, P. intermedia, F. nucleatum, T.
forsythia, and total bacterial counts at
6 months (P > 0.05) (real-time PCR)

Gomi et al. (47) Full-mouth scaling and root
planing+azithromycin
Scaling and root The test group showed lower mean Red complex species, P. intermedia, A.
planing probing depth (2.4  0.8 mm) than the actinomycetemcomitans and Prevotella
control group (3.3  0.4 mm) (P < 0.05) nigrescens were not detected in the test
and no difference was observed between group until 13 weeks. In the control
groups in mean clinical attachment level group, P. gingivalis, T. forsythia and
(azithromycin, 4.8  1.0 mm; scaling and P. intermedia were detected after
root planing, 5.7  1.0 mm) (P > 0.05) at 5 weeks (PCR)
25 weeks

155
Systemic antibiotics in periodontal therapy
 Feres et al.

5 mm at baseline (mean of 43.9 sites). At 1 year

and P. gingivalis (P < 0.05). P. intermedia

Only the test group showed a reduction in

was reduced in both groups (P < 0.05) at

post-treatment, only 18.2% of subjects receiving scal-

gradually in the control group at 1 year

the levels of A. actinomycetemcomitans

Periodontal pathogens were reduced in

ing and root planing alone had reached the clinical

treatment. They tended to increase

both test groups immediately after
Principal microbiological ndings endpoint for treatment (i.e. low-risk prole for further
disease progression) compared with 57.7% in the
metronidazole group and 63% in the metronidazole +
amoxicillin group. On the other hand, 67.3% of the

2 months (Culture)
subjects in the control group still had at least nine
sites with probing depth 5 mm at 1 year (i.e. a high-

(real time PCR)

risk prole for further disease progression) compared
with 33.4% and 18% in the metronidazole and metro-
(method)

nidazole + amoxicillin groups, respectively. The per-

centage of subjects presenting residual sites with
probing depth 6 mm was also a relevant nding.
(P < 0.05) in sites with initial PD 5 mm

Even though all subjects included in this analysis had

differences were observed between test

improvements in mean probing depth
scaling and root planing, 1.5 mm) and

and clinical attachment level than the

control group (P < 0.05) at 1 year. No
(metronidazole+amoxicillin, 2.2 mm;

(metronidazole+amoxicillin, 1.9 mm;

six or more of these deep sites at baseline (average of

Full-mouth scaling and The test group showed greater mean

scaling and root planing, 1.2 mm)

25.2 sites), 51.8% of subjects who received adjunctive

Both test groups showed greater

metronidazole + amoxicillin did not harbor any site

with probing depth 6 mm at 1 year compared with
Principal clinical ndings

probing depth reduction

clinical attachment gain

only 14.5% in the control group. This is an important

piece of information because it has been suggested
groups (P > 0.05)

that the presence of even one site with probing depth

6 mm after periodontal treatment may increase the
at 2 months

risk for future disease progression (132). The data for

residual sites clearly showed a benet of the use of
both antibiotic protocols, with a nonsignicant trend
towards greater additional benets when the two
root planing+placebo

drugs were combined. This trend was conrmed

when the changes in probing depth and in clinical
Scaling and root

attachment level from baseline to the follow-up

appointments were evaluated. A statistically signi-
cant benet for metronidazole + amoxicillin over
planing
Control

metronidazole alone was observed for probing depth

reduction and clinical attachment gain in initially
intermediate sites (Table 8). These data suggest that
the adjunctive use of these systemic antibiotics, espe-
planing+metronidazole+amoxicillin

cially metronidazole + amoxicillin, may benet deep,

as well as intermediate pockets.
Partial-mouth scaling and root

In accordance with the clinical changes, there were

Full-mouth scaling and root

Full-mouth scaling and root

marked differences among treatments in changing

planing+azithromycin

planing+azithromycin

the subgingival microbial composition. The evalua-

tion of the bacterial counts over the course of the
study presented in Fig. 4 shows that more species
were statistically signicantly affected when the two
Treatment

antibiotics were combined, in comparison with scal-

ing and root planing alone or with metronidazole.
Test
Table 5. (Continued)

The treatments were effective in reducing the levels

of all three species from the red complex. However,
Yashima et al.

subjects receiving one of the antibiotic protocols had

Moentaghavi
Geographic

et al. (141)
References

signicantly lower levels of these pathogens at 1 year,

Region/

as well as of four putative pathogens from the orange

(220)

complex: F. nucleatum ssp. polymorphum, F. nuclea-

tum ssp. vincentii, P. intermedia and E. nodatum.

156
 Systemic antibiotics in periodontal therapy

Table 6. Number of sites with probing depth 5, 6 and 7 mm at baseline and at 3 months, 6 months and 1-year
post-treatment as well as changes in number of sites with probing depth 5 mm between baseline and 1 year post-
treatment, in 154 subjects with advanced periodontitis treated with scaling and root planing alone, with scaling and
root planing combined with metronidazole or with scaling and root planing combined with metronidazole + amoxicil-
lin

Probing Time point Treatment groups P*

depth
Scaling and root Scaling and Scaling and root
planing (n = 55) root planing + planing + metronidazole +
metronidazole amoxicillin (n = 54)
(n = 45)

5 mm Baseline 43.9  20.5a 37.1  19.5a 42.4  22.3a 0.244

3 months 18.4  17.4 A,b
10.7  12.2 B,b
8.8  11.6 B,b
0.001
6 months 16.6  15.5 A,b
9.6  11.7 B,b
6.4  7.6 B,b
0.000
1 year 18.0  15.3 A,b
8.0  11.2 B,b
5.3  6.3 B,b
0.000
D 01 year 25.8  15.7 A
29.0  16.6 37.1  18.8 B
0.002
6 mm Baseline 24.0  17.4 a
20.7  16.1 a
25.2  20.9 a
0.436
3 months 8.8  11.3A,b 4.0  7.4B,b 3.1  6.7B,b 0.001
6 months 8.0  10.8 A,b
4.1  8.1 B,b
2.3  4.3 B,b
0.001
1 year 7.7  10.5 A,b
3.4  6.7 B,b
1.8  3.4 B,b
0.000
7 mm Baseline 13.0  13.8 a
9.8  11.5 a
14.6  18.3 a
0.335
3 months 4.6  7.7 A,b
1.9  4.3 B,b
1.5  4.4 B,b
0.012
6 months 4.0  7.2 A,b
1.6  4.6 B,b
1.1  3.0 B,b
0.012
1 year 3.8  7.1 A,b
1.2  4.0 B,b
0.9  2.7 B,b
0.005
Values are given as mean  SD. The signicance of differences among time points was determined using repeated-measures analysis of variance and Tukeys multi-
ple comparison test (different lower-case letters indicate signicant differences between time points). *The signicance of differences among groups at each time
point was assessed using the one-way analysis of variance and Tukeys multiple comparison tests (different capital letters indicate signicant differences between
pairs of groups).

Table 7. Assessment of the risk of disease progression according to Lang & Tonetti (105) *, as well as the percentage of
subjects with no, one or two, or three or more sites with probing depth 6 mm and 7 mm at 1 year post-treatment,
in 154 subjects with advanced periodontitis treated with scaling and root planing alone, scaling and root planing com-
bined with metronidazole, or scaling and root planing combined with metronidazole + amoxicillin

Variables Categories Treatment groups P

Scaling and Scaling and Scaling and

root planing root planing + root planing +
(n = 55) metronidazole metronidazole +
(n = 45) amoxicillin (n = 54)

Risk for disease Low risk 18.2 57.7 63.0 <0.000

progression
Moderate risk 14.5 8.9 13.0
High risk 67.3 33.4 18.0
Probing 0 14.5 44.4 51.8 <0.000
depth 6 mm
12 69.0 26.6 24.0
3 14.5 29.0 24.2
Probing 0 36.4 68.8 72.2 0.000
depth 7 mm
12 25.5 20.0 16.6
3 38.1 11.2 11.2
Values are given as percentage of subjects. *Low risk, presence of at most four sites with probing depth 5 mm (the clinical endpoint of treatment); moderate risk,
presence of ve to eight sites with probing depth 5 mm; high risk, presence of nine or more sites with probing depth 5 mm. The signicance of differences among
groups was assessed using the chi-square test.

157
Feres et al.

Table 8. Changes in probing depth and in clinical attachment between baseline and 3 months, baseline and 6 months
and baseline and 1 year post-treatment in 154 subjects with advanced periodontitis treated with scaling and root plan-
ing alone, scaling and root planing combined with metronidazole, or scaling and root planing combined with metroni-
dazole + amoxicillin

Baseline Variables Time period Treatment groups P*

probing depth
Scaling and Scaling and Scaling and
root planing root planing + root planing +
(n = 55) metronidazole metronidazole +
(n = 45) amoxicillin (n = 54)

46 mm Probing depth 03 months 1.2  0.4A 1.5  0.5B 1.8  0.5C 0.000
reduction (mm)
06 months 1.3  0.5 A
1.6  0.5 B
1.9  0.5 C
0.000
01 year 1.3  0.5 A
1.7  0.5 B
2.0  0.4 C
0.000
Clinical attachment 03 months 1.0  0.5 A
1.2  0.5 B
1.5  0.4 C
0.000
gain (mm)
06 months 1.1  0.4 A
1.3  0.5 B
1.6  0.4 C
0.000
01 year 1.1  0.5 A
1.4  0.5 B
1.7  0.4 C
0.000
7 mm Probing depth 03 months 2.6  1.0 A
3.2  0.9 B
3.8  0.9 C
0.000
reduction (mm)
06 months 2.9  1.2 A
3.5  1.0 B
3.9  1.0 C
0.000
01 year 3.0  1.3 A
3.8  0.9 B
4.0  1.0 B
0.000
Clinical attachment 03 months 2.0  0.9 A
2.6  1.1 B
3.0  0.7 B
0.000
gain (mm)
06 months 2.3  1.0A 2.8  1.1B 3.3  0.9B 0.000
01 year 2.5  1.1 A
3.1  1.1 B
3.3  0.9 B
0.000
Values are given as mean  SD. *The signicance of differences among groups at each time point was assessed using one-way analysis of variance and Tukeys mul-
tiple comparison tests (different letters indicate signicant differences between pairs of groups).

Figure 5 demonstrates that the overall proportions of
the complexes harboring pathogens decreased, and
the overall proportions of those harboring benecial
species increased, over the course of the study in all
treatment groups. However, at 1 year, subjects taking
antibiotics had lower mean proportions of red and
orange complexes in comparison with those receiving
scaling and root planing only, whereas those subjects
taking metronidazole + amoxicillin had an additional
benet, which was higher proportions of Actinomyces
species in comparison with the other two treatments.
The microbial endpoint for treatment was achieved
by 32%, 60% and 71% of the subjects in the scaling
and root planing, metronidazole and metronida-
zole+amoxicillin groups, respectively.
As stated in the rst section of this article, the
advantage of one anti-infective therapy over another
is most probably related to their capabilities of chang-
ing the complex and pathogenic microbial ecology of
the oral cavity in the presence of periodontal infec-
tion. This assumption was nicely elucidated by the
data presented in this subitem, in which a marked
clinical benet from both antibiotic protocols was
observed compared with those obtained with scaling
and root planing alone. Moreover, these clinical ben-
ets were accompanied by a more benecial change
in the microbial prole, including a greater reduction
in the proportions of pathogens and an increase in
host-compatible species. In addition, the slight supe-
riority of metronidazole + amoxicillin over metroni-
dazole alone was probably a result of the more
profound effect of the combination of the two drugs
in increasing proportions of the benecial Actinomy-
ces species.
Azithromycin, a wide-spectrum bacteriostatic mac-
rolide, emerged as a promising drug in medicine in
the early 1990s (9, 89, 178) and more recently in den-
tistry (60, 61, 72, 129, 152, 220). Azithromycin presents
good pharmacological properties, such as rapid
absorption, high tissue concentration (89) and long
half-life (45, 46), allowing once-daily dosing (500 mg)
for 36 days (86). This simple prescription protocol
and the low incidence of side effects associated with
the use of azithromycin tends to reduce issues related
to patient compliance, which is considered a major
problem of several antibiotic protocols, such as met-
ronidazole and metronidazole + amoxicillin, which
require the intake of three or six tablets a day for 7
14 days (42, 59). However, the results of the few ran-
domized clinical trials that have evaluated the effects
of azithromycin in periodontal treatment are some-
how controversial (29, 34, 47, 60, 72, 77, 129, 152, 177,

158
 Systemic antibiotics in periodontal therapy

SRP SRP+MTZ SRP+MTZ+AMX 1 year

Counts x 105 0.0 9.2 18.3 27.5 36.6 0.0 9.2 18.3 27.5 36.6 0.0 9.2 18.3 27.5 36.6 0.0 9.2 18.3 27.5 36.6
A.gerencseriae
A.israelii *** ** ***
A.naeslundii Actinomyces
A.oris
A.odontolyticus *
V.parvulla ** Purple ***
S.gordonii
S.intermedius **
S.mitis Yellow
S.oralis *
S.sanguinis *
A. actinomycetemcomitans
C.gingivalis ***
C.ochracea Green
C.sputigena
E.corrodens * **
C.gracilis ** *
C.rectus ** Baseline SRP
C.showae *** *** ***
*** 3 months *** SRP+MTZ
E.nodatum B AA
F.nucleatum.ssp.nucleatum *** Orange *** 6 months *** SRP+MTZ+AMX
F.nucleatum.ssp.polymorphum *** * 1 year *** B B A
F.nucleatum.ssp.vincentii ** ** B B A
F.periodonticum ***
P.micra ** *** ***
P.intermedia *** ** *** B B A
P.nigrescens *** ***
S.constellatus **
T.forsythia *** ** B B A
P.gingivalis *** *** *** B B A
T.denticola Red *** *** ***
B B A
E.saburreum *** *** ***
G.morbillorum ** **
L.buccalis * *
P.acnes
P.melaninogenica Others
N.mucosa * **
S.anginosus
S.noxia
T.socranskii

Fig. 4. Proles of the mean counts (3105) of 40 taxa in
subgingival biolm samples taken from subjects with
advanced periodontitis treated with scaling and root plan-
ing (SRP), alone (n = 55), combined with 400 mg of metro-
nidazole (three times daily for 14 days) (SRP+MTZ)
(n = 45) or combined with 400 mg of metronidazole +
500 mg of amoxicillin (three times daily for 14 days)
(SRP+MTZ+AMX) (n = 54), at baseline, and at 3 months,
6 months and 1 year post-treatment. The panel at the far
right of the gure superimposes the microbial proles at
1 year to permit easier comparison among groups. Nine
subgingival biolm samples were taken from each subject
at each time point and were analyzed separately to deter-
mine their content of 40 species of bacteria. The species
were ordered and grouped according to the microbial
complexes described by Socransky et al. (193). The mean
values for each species were averaged within a subject and
then across subjects in each group at each time point. The
signicance of differences among time points was deter-
mined using the Friedman test adjusted for multiple com-
parisons [Socransky et al. (199)] (*P < 0.05; **P < 0.01;
***P < 0.001). The signicance of differences among
groups at 1 year post-treatment was determined using
KruskalWallis and Dunns multiple comparison tests (dif-
ferent letters indicate signicant differences between pairs
of groups, P < 0.05).

192, 220). Although some authors demonstrated cols (42), we decided to make a direct comparison
certain benets when azithromycin was used as an between the effects of azithromycin and metronida-
adjunct to mechanical debridement in the treatment zole + amoxicillin in the treatment of nonsmoker sub-
of aggressive periodontitis (60), smokers (129) or in jects with advanced chronic periodontitis by
cases of mild/moderate chronic periodontitis (72, compiling the data from three randomized clinical
152, 192), others could not show a benet (34, 77, trials (42, 177, 184). It should be pointed out that the
177). In the light of this literature and of the data pre- subjects included in the study by Sampaio et al. (177)
sented in Tables 68 and Figs 4 and 5 on the bene- presented very advanced disease, and thus, in order
cial effects of metronidazole or metronidazole + to provide the best comparison possible, we selected
amoxicillin in the treatment of advanced periodonti- subjects with a similar disease pattern from the two
tis, the question that arises is whether azithromycin other studies (42, 184) by using a cut-off point of the
would achieve the same outcomes as either one of presence of at least 25 sites with probing depth
these two antibiotic protocols. Taking into consider- 5 mm at baseline. The results of this analysis are
ation that the benets of the adjunctive metronida- presented in Tables 9 and 10 and Figs 6 and 7. Azi-
zole + amoxicillin were somewhat superior to those thromycin was given at a dose of 500 mg a day for
observed with metronidazole only (42, 130, 184) 5 days and metronidazole and amoxicillin were given
(Tables 68 and Fig. 4) and that the side effects do three times daily for 14 days, at a dose of 400 mg and
not differ signicantly between these two drug proto- 500 mg, respectively. They received clinical and

159
Feres et al.
Fig. 5. Cumulative mean proportions of microbial com-
plexes, as well as pie charts describing the mean propor-
tion of microbial complexes at 1 year post-treatment in
subgingival biolm samples taken from subjects with
advanced periodontitis treated with scaling and root
planing (SRP), alone (n = 55), combined with 400 mg of
metronidazole (three times daily for 14 days) (SRP+MTZ)
(n = 45) or combined with 400 mg of metronidazole +
500 mg of amoxicillin (three times daily for 14 days)
(SRP+MTX+AMX) (n = 54), at baseline and at 3 months, 6
months and 1 year post-treatment. Nine subgingival bio-
lm samples were taken from each subject at each time
point and were analyzed separately to determine their
content of the 40 species of bacteria listed in Fig. 4. The
percentage of DNA probe counts for each species was
microbiological monitoring and periodontal mainte-
nance at 3 and 6 months as well as at 1 year post-
treatment. The mean baseline probing depth and
clinical attachment level was, respectively, 4.8 mm
and 5.3 mm for the scaling and root planing group,
4.7 mm and 5.3 mm for the azithromycin group and
4.7 mm and 5.1 mm for the metronidazole + amoxi-
cillin group. No statistically signicant differences
were observed among groups at baseline for any clini-
cal parameter (P > 0.05, data not shown). As men-
tioned above, the subjects selected for this analysis
presented very advanced periodontitis, as indicated
by the high mean probing depth values and the high
number of initially deep sites presented in Table 9. As
a result of this specic clinical prole, the mean num-
ber of sites with probing depth 5 mm in these sub-
jects was much higher (approximately 60 sites) than
that observed in subjects from the previous analysis
(approximately 40 sites) (Table 6). This is probably
why only a few subjects reached the clinical endpoint
for treatment in this analysis: 0%, 12.3% and 20%, in
the scaling and root planing, azithromycin and met-
ronidazole + amoxicillin groups, respectively. At
160
determined at each site, then averaged within a subject
and then across subjects in each group at each time
point. The mean proportion of each species was summed
in order to determine the proportion of each complex.
The colors represent the different complexes described by
Socransky et al. (193). The grey color (Others) repre-
sents species that did not fall into any complex, and Acti-
nomyces spp. are represented in blue. The signicance of
differences among time points was determined using
repeated-measures analysis of variance (***P < 0.001).
The signicance of differences among groups at 1 year
post-treatment was determined using one-way analysis of
variance and Tukeys multiple comparison tests (different
letters indicate signicant differences between pairs of
groups, P < 0.05).
1 year post-treatment, subjects treated with scaling
and root planing only presented a much higher mean
number of sites with probing depth 5 mm (n = 29)
than did those treated with adjunctive metronida-
zole+amoxicillin (n = 9.6; P < 0.05). The mean num-
ber of these residual sites for subjects who took
azithromycin remained in between (n = 19.1), but did
not differ signicantly from the numbers in the other
two groups (P > 0.05). These results indicate an
advantage of treatment with metronidazole + amoxi-
cillin over treatment with azithromycin, which was
reinforced by the data presented in Table 10 for
changes from baseline to 1 year in probing depth and
clinical attachment in initially intermediate and deep
sites. Here again, only the metronidazole + amoxicil-
lin-treated group showed statistically signicantly
greater reduction in probing depth and gain in clini-
cal attachment than the group treated with scaling
and root planing only. There was very good agree-
ment between the microbiological and clinical
results. Figure 6 shows that the adjunctive use of
metronidazole+amoxicillin resulted in a more pro-
found benecial change in the subgingival microbial
 Systemic antibiotics in periodontal therapy

Table 9. Number of sites with probing depth 5, 6 and 7 mm at baseline and at 3 months, 6 months and 1-year
post-treatment as well as changes in number of sites with probing depth 5 mm between baseline and 1 year post-
treatment, in 45 subjects with very advanced periodontitis treated with scaling and root planing alone, scaling and root
planing combined with azithromycin, or scaling and root planing combined with metronidazole + amoxicillin

Probing Time point Treatment groups P*

depth
Scaling and Scaling and root Scaling and root planing +
root planing planing + azithromycin metronidazole +
(n = 15) (n = 15) amoxicillin (n = 15)

5 mm Baseline 63.4  23.3a 60.2  25.4a 59.8  19.8a 0.191

3 months 33.8  26.3 A,b
14.5  7.5 B,b
12.1  11.4 B,b
0.005
6 months 28.4  22.2A,b 15.9  11.1b 11.2  8.0B,b 0.013
1 year 29.0  21.0 A,b
19.1  15.3 b
9.6  6.4 B,b
0.005
D 01 year 34.4  18.3 A
41.1  21.1 50.2  18.5 B
0.044
6 mm Baseline 48.4  22.0 a
42.9  22.9 a
43.4  16.7 a
0.547
3 months 17.8  16.5 A,b
4.2  3.6 B
4.7  9.6 B,b
0.004
6 months 15.0  15.4 A,b
5.4  5.5 B
4.2  6.1 B,b
0.014
1 year 13.4  15.6 b
6.9  7.5 b
4.2  4.8 b
0.054
7 mm Baseline 32.8  17.2 a
25.5  16.4 a
29.2  14.6 a
0.467
3 months 8.6  10.0 A,b
1.6  2.5 B,b
1.8  7.46 B,b
0.036
6 months 7.2  9.1 b
1.9  2.6 b
1.9  5.0 b
0.057
1 year 6.0  8.7 b
2.0  3.3 b
2.5  4.7 b
0.162
Values are given as mean  SD. *The signicance of differences among time points was determined using repeated-measures analysis of variance and Tukeys multiple
comparison test (different lower-case letters indicate signicant differences between time points). The signicance of differences among groups at each time point was
assessed using the one-way analysis of variance and Tukeys multiple comparison tests (different capital letters indicate signicant differences between pairs of groups).

Table 10. Changes in probing depth and clinical attachment between baseline and 3 months, baseline and 6 months
and baseline and 1 year post-treatment in 45 subjects with very advanced periodontitis treated with scaling and root
planing alone, scaling and root planing combined with azithromycin, or scaling and root planing combined with met-
ronidazole + amoxicillin

Baseline Variables Time period Treatment groups P*

probing
depth Scaling and root Scaling and Scaling and
planing (n = 15) root planing + root planing +
azithromycin metronidazole +
(n = 15) amoxicillin (n = 15)

46 mm Probing depth 03 months 1.3  0.5A 1.7  0.3 1.8  0.5B 0.024
reduction (mm)
06 months 1.5  0.4 A
1.6  0.3 1.9  0.5 B
0.026
01 year 1.5  0.5 A
1.5  0.4 A
2.1  0.4 B
0.002
Clinical attachment 03 months 0.9  0.3 A
1.2  0.3 1.4  0.5 B
0.002
gain (mm)
06 months 1.0  0.3A 1.2  0.4 1.5  0.4B 0.001
01 year 1.1  0.6 A
1.1  0.4 A
1.8  0.5 B
0.001
7 mm Probing depth 03 months 2.5  0.7 A
3.4  0.6 B
3.9  0.7 B
0.000
reduction (mm)
06 months 2.8  0.8 A
3.4  0.5 4.3  0.8 B
0.000
01 year 2.9  0.8 A
3.3  0.9 4.4  0.7 B
0.000
Clinical attachment 03 months 1.5  0.7 A
2.5  0.6 C
3.0  0.5 B
0.000
gain (mm)
06 months 1.8  0.6 A
2.5  0.6 C
3.4  0.7 B
0.000
01 year 2.0  1.2 A
2.6  0.8 3.5  0.6 B
0.000
Values are given as mean  SD. *The signicance of differences among groups at each time point was assessed using one-way analysis of variance and Tukeys mul-
tiple comparison tests (different letters indicate signicant differences between pairs of groups).

161
Feres et al.

SRP SRP+AZT SRP+MTZ+AMX

DNA probe counts (%) 0.0 4.6 9.1 13.7 18.3 0.0 4.6 9.1 13.7 18.3 0.0 4.6 9.1 13.7 18.3

A.gerencseriae
A.israelii *
A.naeslundii Actinos
A.oris ** **
A.odontolyticus Purple
V.parvulla
S.gordonii
S.intermedius **
Yellow
S.mitis
S.oralis
S.sanguinis
A. actinomycetemcomitans **
C.gingivalis
C.ochracea Green
C.sputigena
E.corrodens
C.gracilis
C.rectus
C.showae **
Baseline
E.nodatum
F.nucleatum.ssp.nucleatum 6 months
Orange 1 year
F.nucleatum.ssp.polymorphum
F.nucleatum.ssp.vincentii
F.periodonticum
P.micra
P.intermedia
P.nigrescens
S.constellatus
T.forsythia **
P.gingivalis Red ***
*** *** ***
T.denticola
E.saburreum ***
G.morbillorum
L.buccalis
P.acnes Others
P.melaninogenica
N.mucosa
S.anginosus
S.noxia
T.socranskii

Fig. 6. Proles of the mean proportions (%) of 40 taxa in
subgingival biolm samples taken from subjects with very
advanced periodontitis treated with scaling and root
planing (SRP) alone (n = 15), combined with 500 mg of
azithromycin (once a day for 5 days) (SRP+AZT)
(n = 15) or combined with 400 mg of metronida-
zole + 500 mg of amoxicillin (three times daily for 14 days)
(SRP+MTX+AMX) (n = 15), at baseline, and at 6 months
and 1 year post-treatment. Nine subgingival biolm sam-
ples were taken from each subject at each time point and
were analyzed separately to determine their content of 40
species of bacteria. The species were ordered and grouped
according to the microbial complexes described by Socran-
sky et al. (193). The percentage of DNA probe counts for
each species was determined at each site, then averaged
within a subject and then across subjects in each group at
each time point. The signicance of differences among
time points was determined using the Friedman test
adjusted for multiple comparisons [Socransky et al. (199)]
(*P < 0.05; **P < 0.01; ***P < 0.001).

prole than that of azithromycin. It may be observed
that scaling and root planing + metronidazole +
amoxicillin was the only treatment that signicantly
reduced the proportions of the three pathogens of the
red complex. Moreover, this treatment was able to
increase the proportions of three benecial bacterial
species (Actinomyces gerencseriae, A. naeslundii and
Streptococcus sanguinis as opposed to only one in the
azithromycin group (A. naeslundii). Even though scal-
ing and root planing also led to the increase of some
host-compatible species, these changes were not sta-
tistically signicant from baseline to 1 year in this
group. Figure 7 shows the changes that occurred in
the microbial complexes with the use of the different
treatments. All three treatments caused a benecial
change in the microbial prole; however, one impor-
tant aspect to point out in this gure is the residual
mean proportion of red complex in the three groups.
These species accounted for approximately 12% of
the 40 species evaluated in the scaling and root
planing and azithromycin groups, and for 4.9% in
the metronidazole + amoxicillin group. Previous
publications have demonstrated a mean of 10%
remaining red complex in subjects with advanced
periodontitis treated by scaling and root planing, but
this proportion is noticeably lower (33.5%) when sys-
temic antibiotics are used as adjunct to the mechani-
cal treatment (130, 138, 184). Therefore, 12%
remaining mean proportions of red complex in the
azithromycin-treated subjects was a rather
disappointing result and is probably one of the major
reasons for the lack of an additional clinical effect of
azithromycin over that obtained with scaling and root
planing only, as recently highlighted by Sampaio

162

Fig. 7. Pie charts describing the mean proportions of
microbial complexes in subgingival biolm samples taken
from subjects with very advanced periodontitis treated with
scaling and root planing (SRP), alone (n = 15), combined
with 500 mg of azithromycin (SRP + AZT) (once a day for
5 days, n = 15) or combined with 400 mg of metronida-
zole + 500 mg of amoxicillin (three times daily for 14 days)
(SRP + MTZ + AMX) (n = 15), at baseline and 1 year post-
treatment. Nine subgingival biolm samples were taken
from each subject at each time point and were analyzed
separately to determine their content of the 40 species of
bacteria listed in Fig. 6. The percentage of DNA probe
counts for each species was determined at each site, then
et al. (177). The microbial endpoint for treatment was
achieved by 20%, 33.3% and 66.6% of the subjects in
the scaling and root planing, azithromycin and met-
ronidazole+amoxicillin groups, respectively. These
results indicate that azithromycin does not yield the
same benets of metronidazole + amoxicillin in the
treatment of advanced chronic periodontitis. In fact,
the adjunctive use of this drug did not offer statisti-
cally signicant advantages in comparison with scal-
ing and root planing only for this group of nonsmoker
subjects with very advanced chronic periodontitis.
However, as some studies have reported modest ben-
ets with the use of azithromycin in smokers (129),
mild/moderate chronic periodontitis (72, 152) and
aggressive periodontitis (60), future studies using azi-
thromycin for the treatment of these groups of sub-
jects could be justied. Nevertheless, it should be
emphasized that the results of the only clinical trial
that has directly compared the effects of azithromycin
and metronidazole in subjects with mild/moderate
chronic periodontitis were not very encouraging (72).
The authors detected a statistically signicant clinical
advantage for metronidazole plus scaling and root
planing in comparison with scaling and root planing
only, but not for azithromycin plus scaling and root
Systemic antibiotics in periodontal therapy
averaged within a subject and then across subjects in each
group at each time point. The mean proportion of each spe-
cies was summed in order to determine the proportion of
each complex. The colors represent the different complexes
described by Socransky et al. (193). The grey color repre-
sents species that did not fall into any complex, and Actino-
myces spp. are represented in blue. The signicance of
differences between time points was determined using the
Wilcoxon test (*P < 0.05). The signicance of differences
among groups at baseline and at 1 year post-treatment was
determined using KruskalWallis and Dunns multiple
comparison tests (different letters indicate signicant dif-
ferences between pairs of groups, P < 0.05).
planing. In summary, despite the good pharmacologi-
cal properties and its easy dosage regimen, at this
point azithromycin does not seem to feature among
the promising drugs for the treatment of periodontal
infections. This might be related to the fact that azi-
thromycin is a bacteriostatic drug, as opposed to met-
ronidazole and amoxicillin, which are bactericidal. As
mentioned at the start of this article, good and sus-
tained clinical effects from treatments require a very
rapid and massive reduction of the total bacterial lev-
els, especially of the strictly anaerobic pathogens, in
order to allow the best possible recolonization with
host-compatible species (71, 208). This goal is proba-
bly more difcult to achieve with bacteriostatic drugs
such as azithromycin, other macrolides and tetracy-
clines.
Collectively, the data outlined in this subitem sug-
gest that subjects with advanced or very advanced
periodontitis would signicantly benet from the
adjunctive use of metronidazole or metronidazole +
amoxicillin. The most important advantage of these
two antibiotic protocols over scaling and root plan-
ing, alone or combined with azithromycin, was the
statistically signicant lower mean number/percent-
age of sites and of subjects with probing depth
163
Feres et al.
5 mm up to 1 year after treatment. These results
have direct clinical implications because they indicate
a reduced need for periodontal surgery in subjects
receiving one of these antibiotic protocols, as previ-
ously suggested by Loesche and coworkers (115, 116).
Moreover, subjects taking adjunctive metronidazole +
amoxicillin exhibited some clinical and microbiologi-
cal benets compared with those achieved with met-
ronidazole only, and the frequency of adverse events
did not differ signicantly between the two treat-
ments.
It is also important to realize that certain periodon-
tal conditions, such as refractory (21) or apical peri-
odontitis (205), and periodontal destruction in
immunocompromised patients (188), have been asso-
ciated with superinfecting or nonoral microorganisms
that might not respond well to metronidazole and
amoxicillin. This would be the case for beta-lactam-
ase-producing Staphylococcus aureus (25, 93), some
enteric gram-negative rods, Pseudomonas species and
Candida albicans (27, 188). In this context, some
authors have suggested that the combination of met-
ronidazole and ciprooxacin could be effective in the
treatment of periodontitis associated with enteric
rods and Pseudomonas (186, 191), and in theory this
treatment could also be useful in patients allergic to
penicillin (159). Therefore, conducting randomized
clinical trials to appraise the effectiveness of cipro-
oxacin, alone or combined with metronidazole, in
periodontal treatment or to directly compare metro-
nidazole+ciprooxacin and metronidazole+amoxicillin
would be of value to clinicians and patients.
Which subjects would benet most from
the antibiotic therapy
The data presented in the previous subitem, as well
as the available literature (Tables 4 and 5; 179, 180,
223), suggest that subjects with advanced (Tables 68,
Figs 4 and 5) or very advanced (Tables 9 and 10,
Figs 6 and 7) periodontitis would signicantly benet
from adjunctive antibiotics, especially metronidazole
+ amoxicillin. Furthermore, the few randomized clini-
cal trials that assessed the effects of systemic antibiot-
ics in the treatment of mild to moderate periodontitis
(29, 66, 72, 152) showed clinical and microbiological
benets over those obtained with scaling and root
planing alone when azithromycin (29, 152) or metro-
nidazole (66, 72) were associated with scaling and
root planing. Nevertheless, there is an overall percep-
tion in periodontology that subjects with mild to
moderate periodontitis would not benet from sys-
temic antibiotics, or if these benets exist they would
164
not be important enough to justify the use of a sys-
temic drug. In an attempt to assess the effects of sys-
temic antibiotics in the treatment of moderate
periodontitis we selected subjects from our database
that presented, at most, 20 sites with a probing depth
of 5 mm at baseline. These subjects were divided
according to the treatment received as follows:
mechanical treatment, either alone (control group) or
with adjunctive metronidazole or metronidazole +
amoxicillin (test group). The subjects received clinical
and microbiological monitoring and periodontal
maintenance at 3 months, 6 months and 1 year post-
treatment. At baseline, no statistically signicant dif-
ferences were observed between groups for the clini-
cal parameters evaluated (P > 0.05, data not shown).
The mean baseline probing depth was 2.9 mm for the
two groups, and the mean clinical attachment level
was 3.4 mm and 3.5 mm for the control and test
groups, respectively. The mean number of sites with
baseline probing depth 5 mm was 15.5 in the scaling
and root planing group and 14.3 in the test group
(range: 920 sites; Table 11). These baseline clinical
data conrm the moderate degree of periodontal
destruction in these subjects. At 1 year post-therapy,
those who took antibiotics harbored fewer sites with
probing depth 5, 6 and 7 mm, in comparison with
the control group. These differences were statistically
signicant for the probing depth 6 and 7 mm cate-
gories. Subjects taking systemic metronidazole +
amoxicillin also showed greater probing depth reduc-
tion and clinical attachment gain in initially interme-
diate and deep sites, even though statistical
signicance was not achieved (Table 12). However, it
should be highlighted that this analysis could be
underpowered as a result of the low number of sub-
jects in the scaling and root planing group and there-
fore the lack of statistical signicance in this case
should be interpreted with caution. For example, the
difference between groups for probing depth reduc-
tion and clinical attachment gain in initially deep
sites was about 1 mm, in favor of the antibiotic group
(P = 0.067); a difference considered clinically relevant
and used for sample size calculation in several ran-
domized clinical trials. Presumably a rather relevant
and consistent nding relates to the percentage of
subjects who reached the clinical endpoint for treat-
ment at 1 year (Table 13), which was 95% (19/20) in
the antibiotic group compared with 61.5% (eight of
13) in the control group. On the other hand, 30.8%
(four of 13) of the subjects receiving scaling and root
planing still had a high risk prole for disease recur-
rence at 1 year post-treatment, as opposed to none of
the 20 subjects receiving adjunctive metronidazole or
 Systemic antibiotics in periodontal therapy

Table 11. Number of sites with probing depth 5, 6 and 7 mm at baseline and at 3 months, 6 months and 1-year
post-treatment, as well as changes in number of sites with probing depth 5 mm between baseline and 1 year post-
treatment in 33 subjects with moderate periodontitis treated with scaling and root planing alone or scaling and root
planing combined with systemic antibiotics (metronidazole or metronidazole + amoxicillin)

Probing depth Time point Treatment groups P*

Scaling and root Scaling and root

planing (n = 13) planing + Antb (n = 20)

5 mm Baseline 15.5  4.5a 14.3  3.6a 0.275

3 months 7.0  6.0 b
3.8  3.0 b
0.004
6 months 6.5  7.7 b
3.2  3.9 b
0.118
1 year 4.5  5.8 b
2.4  2.2 b
0.144
D 01 year 8.5  6.8 10.5  4.2 0.134
6 mm Baseline 7.0  3.8 a
6.0  3.4 a
0.273
3 months 3.0  2.8b 0.9  1.2b 0.000
6 months 3.3  3.7 b
0.6  1.0 b
0.004
1 year 2.0  3.2 b
0.4  0.6 b
0.037
7 mm Baseline 3.3  2.6 a
2.6  2.9 a
0.344
3 months 1.3  1.3 b
0.3  0.7 b
0.000
6 months 1.7  1.9 b
0.2  0.5 b
0.002
1 year 1.3  1.9 b
0.1  0.3 b
0.007
Values are given as mean  SD. *The signicance of differences between groups at each time point was assessed using the Students t-test. The signicance of differ-
ences among time point was determined using repeated-measures analysis of variance and Tukeys multiple comparison test (different letters indicate signicant
differences between time points). Antb, antibiotic therapy (ve subjects were treated with metronidazole and 15 subjects were treated with metronidazole + amoxi-
cillin).

Table 12. Changes in probing depth and clinical attachment between baseline and 3 months, baseline and 6 months
and baseline and 1 year post-treatment in 33 subjects with moderate periodontitis treated with scaling and root plan-
ing alone or with scaling and root planing combined with systemic antibiotics (metronidazole or metronidazole +
amoxicillin)

Baseline Variables Time period Treatment groups P*

probing depth
Scaling and root Scaling and root
planing (n = 13) planing +Antb (n = 20)

46 mm Probing depth 03 months 1.2  0.5 1.4  0.4 0.106

reduction (mm)
06 months 1.3  0.6 1.5  0.5 0.099
01 year 1.4  0.5 1.6  0.5 0.069
Clinical attachment 03 months 0.9  0.6 1.2  0.5 0.140
gain (mm)
06 months 1.2  0.6 1.4  0.6 0.385
01 year 1.3  0.5 1.5  0.4 0.458
7 mm Probing depth 03 months 2.2  1.0 3.3  1.0 0.000
reduction (mm)
06 months 2.6  1.6 3.6  1.0 0.059
01 year 2.7  1.7 3.7  0.9 0.069
Clinical attachment 03 months 1.9  1.0 2.7  1.2 0.011
gain (mm)
06 months 2.4  1.3 3.3  1.0 0.099
01 year 2.5  1.5 3.5  1.0 0.067
Values are given as mean  SD. *The signicance of differences between groups at each time point was assessed using the Students t-test. Antb, antibiotic therapy
(ve subjects were treated with metronidazole and 15 subjects were treated with metronidazole + amoxicillin).

165
Feres et al.

Table 13. Assessment of the risk of disease progression according to Lang & Tonetti (105),* as well as the percentage
of subjects with no, one to two, or three or more sites with probing depth 6 mm and 7 mm at 1-year post-treatment,
in 33 subjects with moderate periodontitis treated with scaling and root planing alone or scaling and root planing com-
bined with systemic antibiotics (metronidazole + amoxicillin)

Variables Categories Treatment groups P

Scaling and root Scaling and root

planing (n = 13) planing +Antb (n = 20)

Risk for disease Low risk 61.5 95.0 0.014

progression
Moderate risk 7.7 5.0
High risk 30.8 0.0
Probing depth 6 mm 0 53.8 70.0 0.465
12 15.4 30.0
3 30.8 0.0
Probing depth 7 mm 0 61.5 90.0 0.083
12 30.7 10.0
3 7.8 0.0
Values are given as percentage of subjects. *Low risk, at most four sites with probing depth 5 mm (the clinical endpoint of treatment); moderate risk, presence of
ve to eight sites with probing depth 5 mm; high risk, presence of nine or more sites with probing depth 5 mm. The signicance of differences among groups
was assessed using the chi-square test. Antb, antibiotic therapy (ve subjects were treated with metronidazole and 15 subjects were treated with metronida-
zole + amoxicillin).

metronidazole + amoxicillin. This indicates a very
good and steady response to treatment at the subject
level when subjects with moderate periodontitis are
treated with these adjunctive antibiotics. The bene-
cial effect of the antibiotics on the composition of the
subgingival microbiota provides the rationale for
these clinical results (Figs 8 and 9). The changes from
baseline to the other follow-up appointments for
the mean counts of the 40 bacterial species evaluated
are presented in Fig. 8. Subjects taking adjunctive
antibiotics in general showed a better change in the
microbial prole in comparison with those treated
with scaling and root planing. In the test group, from
baseline to 1 year, there was a noticeable reduction
in the mean counts of almost all pathogens from the
red and orange complexes and a concomitant
increase in the mean levels of the majority of the
host-compatible species from the green, yellow and
purple complexes, as well as the Actinomyces species.
In contrast, subjects treated with scaling and root
planing only showed an overall reduction in the levels
of all species evaluated at 1 year, denoting a lower
impact on the microbial prole. This observation may
be better appreciated in Fig. 9, which shows the sub-
gingival microbial proles of the two treatment
groups over the course of the study. Note that at
3 months post-treatment the composition of the sub-
gingival microbiota of both groups was considerably
improved in comparison with baseline. Nonetheless,
some slight advantages observed for the antibiotic
group in the short term were accentuated over the
course of the study. This was particularly notable for
the mean proportions of red complex species, which
was reduced from 3.7% at 3 months to 2.3% at 1 year
in the antibiotic-treated group, and increased from
7.8% at 3 months to 10.1% at 1 year in the scaling
and root planing group. At 1 year, the test group had
statistically signicantly lower proportions of red
complex species and higher proportions of green
complex species in comparison with the control
group, while the proportion of yellow complex was
elevated in the control group. The microbial endpoint
for treatment was achieved by 20% and 87.5% of the
subjects in the scaling and root planing and antibiotic
groups, respectively. Taken together, these microbio-
logical and clinical data indicate that adjunctive met-
ronidazole or metronidazole + amoxicillin yield an
important and constant benet in the treatment of
subjects with moderate periodontitis.
Smokers are a group of individuals who might par-
ticularly benet from systemic antibiotics because
they respond less favorably to mechanical periodon-
tal treatment (69, 81, 94, 104, 140). Apparently, it is
more difcult to reduce periodontal pathogens and to
foster the growth of host-compatible species in smok-
ers than in nonsmokers (28, 57, 129, 130), most prob-
ably because of their impaired immune system and
inammatory response (98, 148, 156, 173). Some clini-
cal studies have suggested that azithromycin (129),
metronidazole (130, 202) or metronidazole + amoxi-
cillin (130, 154) lead to additional clinical and
microbial benets in the periodontal treatment of

166
 Systemic antibiotics in periodontal therapy

3 months 6 months 1 year

Counts x105 5.1 3.6
A.gerencseriae
A.israelii **
A.naeslundii Actinomyces *
A.oris
A.odontolyticus *
V.parvulla Purple
S.gordonii
S.intermedius
S.mitis Yellow *
S.oralis *
S.sanguinis
A. actinomycetemcomitans
C.gingivalis
C.ochracea Green **
C.sputigena
E.corrodens **
C.gracilis SRP
C.rectus *
C.showae SRP+Antb
E.nodatum
F.nucleatum.ssp.nucleatum Orange
F.nucleatum.ssp.polymorphum
F.nucleatum.ssp.vincentii
F.periodonticum *
P.micra
P.intermedia
P.nigrescens
S.constellatus *
T.forsythia
P.gingivalis * * Red
T.denticola * *
E.saburreum
G.morbillorum *
L.buccalis *
P.acnes Others *
P.melaninogenica
N.mucosa
S.anginosus *
S.noxia *
T.socranskii

Fig. 8. Proles of mean change in the counts (3105) of 40
taxa in subgingival biolm samples taken from subjects
with moderate periodontitis treated with scaling and root
planing (SRP) alone (n = 13) or combined with systemic
antibiotics (SRP+Antb) (n = 20; 400 mg of metronidazole
or 400 mg of metronidazole + 500 mg of amoxicillin; three
times daily for 14 days) from baseline to 3 months (left
panel), baseline to 6 months (middle panel) and baseline
to 1 year (right panel) post-treatment. Nine subgingival
biolm samples were taken from each subject at each time
point and were analyzed separately to determine their con-
tent of 40 species of bacteria. The species were ordered and
grouped according to the microbial complexes described
by Socransky et al. (193). Change in counts of each species
at each site in each of the two clinical groups was deter-
mined, averaged within a subject and then across subjects
in each group at each time point. The signicance of differ-
ences between groups at each time point was determined
using the MannWhitney U-test adjusted for multiple com-
parisons [Socransky et al. (199)]; (*P < 0.05; **P < 0.01).

smokers. We recently treated a group of smokers with
scaling and root planing alone, or combined with
metronidazole or metronidazole + amoxicillin, and
observed that the greatest benets on the clinical
parameters and on the subgingival microbial prole
were achieved with the use of the systemic antibiot-
ics, in particular metronidazole + amoxicillin (130).
Unexpected was the lack of effect of all three treat-
ments in reducing the levels and proportions of the
putative pathogens from the orange complex, in par-
ticular Fusobacterium species. In fact, some of these
species increased in counts at 3 months in those sub-
jects treated with scaling and root planing only.
Another investigation from our research group
applied this same study design and microbial analysis
in a group of nonsmokers and observed a signicant
reduction in the proportions of orange complex spe-
cies at 3 months post-treatment, especially with the
use of systemic antibiotics (184). To our knowledge
no studies so far have directly compared the effects of
metronidazole + amoxicillin in the treatment of
smokers and nonsmokers. Therefore, in order to
address this question we carried out an analysis to
compare the effects of this combination of drugs in
smokers and nonsmokers with advanced periodonti-
tis (generalized chronic periodontitis) (Tables 14 and
15, Figs 10 and 11). The mean baseline probing depth
and clinical attachment level were, respectively,
3.9 mm and 4.5 mm for nonsmokers and 4.1 mm
and 4.7 mm for smokers. No statistically signicant
differences were observed between the two groups at
baseline for any clinical parameter evaluated (data
not shown). At 3 months after treatment with
scaling and root planing combined with 400 mg of
metronidazole + 500 mg of amoxicillin (both three
times daily for 14 days), the mean number of sites
with probing depth 5 mm was statistically signi-
cantly lower (n = 7.9) in nonsmokers in comparison
with smokers (n = 11.9) (Table 14). When changes in
mean probing depth and clinical attachment level
were analyzed in initially intermediate and deep sites,
the data showed signicantly greater improvements

167
Feres et al.

Fig. 9. Pie charts describing the mean proportions of
microbial complexes in subgingival biolm samples
taken from subjects with moderate periodontitis treated
with scaling and root planing (SRP), alone (n = 13) or
combined with systemic antibiotics (n = 20; 400 mg of
metronidazole or 400 mg of metronidazole + 500 mg of
amoxicillin; three times daily for 14 days) (SRP+Antb), at
baseline and at 3 months, 6 months and 1 year post-
treatment. Nine subgingival biolm samples were taken
from each subject at each time point and were analyzed
separately to determine their content of the 40 species of
bacteria listed in Fig. 8. The percentage of DNA probe
counts for each species was determined at each site, then
averaged within a subject and then across subjects in
each group, at each time point. The mean proportion of
each species was summed in order to determine the pro-
portion of each complex. The colors represent the differ-
ent complexes described by Socransky et al. (193). The
grey color represents species that did not fall into any
complex, and Actinomyces spp. are represented in blue.
The signicance of differences within each group over
the course of the study was assessed using Friedman and
Dunns multiple comparison tests (*P < 0.05 between
baseline and each time point). The signicance of
differences between groups at each time point was deter-
mined using the MannWhitney U-test (different letters
indicate signicant differences between pairs of groups,
P < 0.05).

Table 14. Number of sites with probing depth 5, 6 and 7 mm at baseline and at 3 months post-treatment, as well
as changes in number of sites with probing depth 5 mm between baseline and 3 months post-treatment, in 36 smok-
ers and 39 nonsmokers with advanced periodontitis treated with scaling and root planing combined with metronida-
zole + amoxicillin

Probing depth Time point Groups P*

Nonsmokers (n = 39) Smokers (n = 36)

5 mm Baseline 48.5  19.9a 53.5  25.3a 0.063

3 months 7.9  8.7 b
11.9  11.1 b
0.043
D 03 months 40.5  16.2 42.4  19.4 0.634
6 mm Baseline 21.8  16.5a 23.4  16.8a 0.617
3 months 2.8  3.5 b
4.4  5.9 b
0.063
7 mm Baseline 10.5  11.1 a
10.6  8.6 a
0.460
3 months 1.2  2.1 b
1.2  1.5 b
0.139
Values are given as mean  SD. *The signicance of differences between groups at each time point was assessed using the MannWhitney U-test. The signicance
of differences between time points was determined using the Wilcoxon test (different letters indicate signicant differences between time points).

in the nonsmokers in comparison with the smokers the nonsmokers. The mean proportions of the red
in both probing depth categories (Table 15). After complex species were reduced in a very similar man-
treatment, 41.6% of the smokers had reached the clin- ner in smokers and nonsmokers (Fig. 10). These
ical endpoint for treatment compared with 61.5% of pathogens accounted for about 5% of the 40 species

168

Table 15. Changes in probing depth and clinical attachment between baseline and 3 months post-treatment in 36
smokers and 39 nonsmokers with advanced periodontitis treated with scaling and root planing combined with metro-
nidazole + amoxicillin
Baseline probing depth Variables
46 mm Probing depth reduction (mm)
Clinical attachment gain (mm)
7 mm Probing depth reduction (mm)
Clinical attachment gain (mm)
Values are given as mean  SD. *The signicance of differences between groups was assessed using the MannWhitney U-test.
Fig. 10. Pie charts describing the mean proportions of
microbial complexes in subgingival biolm samples taken
from 36 smokers and 39 nonsmokers with advanced peri-
odontitis treated with scaling and root planing, combined
with 400 mg of metronidazole (three times daily for
14 days) + 500 mg of amoxicillin (three times daily for
14 days), at baseline and at 3 months post-treatment. Nine
subgingival biolm samples were taken from each subject
at each time point and were analyzed separately to deter-
mine their content of the 40 species of bacteria listed in
Fig. 8. The percentage of DNA probe counts for each species
was determined at each site, then averaged within a subject
evaluated at 3 months in both groups. On the other
hand, the problem detected in our previous study
(130), with regard to the ineffectiveness of treatment
in reducing orange complex species in smokers, was
conrmed in this analysis. In the nonsmoker group,
the orange complex species were reduced from 29.9%
of the microbiota evaluated at baseline to 19% at
3 months (a mean reduction of 11 percentage points),
Systemic antibiotics in periodontal therapy
Groups P*
Nonsmokers (n = 39) Smokers (n = 36)
1.76  0.50 1.41  0.29 0.001
1.31  0.47 1.10  0.33 0.032
3.46  1.05 2.82  0.64 0.000
2.83  0.85 2.32  0.69 0.002
and then across subjects in each group, at each time point.
The mean proportion of each species was summed in order
to determine the proportion of each complex. The colors
represent the different complexes described by Socransky
et al. (193). The grey color represents species that did not
fall into any complex, and Actinomyces spp. are represented
in blue. The signicance of differences between time points
was determined using the Wilcoxon test (*P < 0.05). The
signicance of differences between groups at each time
point was determined using the MannWhitney U-test (dif-
ferent letters indicate signicant differences between pairs
of groups, P < 0.05).
whereas no change in this complex was observed in
the smoker group, which showed approximately 31%
of orange complex species before and after treatment.
The effect of scaling and root planing + metronida-
zole + amoxicillin (or lack of effect, in the case of
smokers) in changing the proportions of orange com-
plex, as well as the effect of this treatment in the pro-
portions of red complex and Actinomyces species
169
Feres et al.
* their suppression is considered an important goal of
15.0
13.1
10.0
Mean proportion (%)
5.0
0.0
5.0
10.0 11.0
15.0
18.7
20.0
Nonsmokers
Fig. 11. Bar charts of the mean changes in the proportions
of Actinomyces species (Actinomyces gerencseriae, Actino-
myces israelii, Actinomyces naeslundii and Actinomyces
oris), orange and red complexes in subgingival biolm
samples taken from 36 smokers and 39 nonsmokers with
advanced periodontitis treated with scaling and root plan-
ing combined with 400 mg of metronidazole (three times
daily for 14 days) + 500 mg of amoxicillin (three times
daily for 14 days), between baseline and 3 months post-
treatment. The signicance of differences between treat-
ment groups was determined using the MannWhitney U-
test (*P < 0.05).
from baseline to 3 months is presented in Fig. 11.
The results conrm that the treatment was equally
effective in reducing red complex species in both
groups, and more effective in reducing orange com-
plex species and in increasing the proportions of Acti-
nomyces in nonsmokers. The microbial endpoint for
treatment was achieved by 18.8% and 43.5% of the
subjects in the smoker and nonsmoker groups,
respectively.
In summary, the subgingival microbial prole of
nonsmokers treated with scaling and root planing +
metronidazole + amoxicillin showed a better shift
than that of smokers treated with the same thera-
peutic protocol. These microbial benets elicited
slightly better clinical outcomes for nonsmokers in
the short-term, but in the light of the outcomes of
treatment from 3 months to 1 year described earlier
in this article (Fig. 9) it seems reasonable to assume
that these differences might intensify in the long
term. The main difference observed between groups
was the complete lack of effectiveness of scaling and
root planing + metronidazole + amoxicillin in reduc-
ing the proportions of the orange complex in smok-
ers. This is a relevant observation because it has
been shown that these species precede the coloniza-
tion of the red complex pathogens and therefore
170
periodontal therapy (101, 198). These results indicate
Actinomyces that the generally poorer response of smokers to
* Orange complex periodontal therapy is related to the persistence of
Red complex
putative pathogens from the orange complex, and
5.4
not from the red complex a common cause of lack
0.8
of clinical improvement in nonsmokers. Future
investigations on potential interactions between sub-
stances present in tobacco and species from the
orange complex or possible host mechanisms
involved in this reduced ability of smokers to inhibit
these pathogens may help to determine enhanced
19.1 periodontal therapies for these individuals.
Smokers
What is the ideal dose and duration of the
systemic antibiotics for their use in the
periodontal treatment?
The optimal dose and duration of systemic antibiotics
for the treatment of periodontal diseases have not yet
been established, often leading to random choices of
antibiotic protocols. These are very important param-
eters that need to be dened before prescribing a sys-
temic antibiotic because they have a direct impact on
the desirable (e.g. infection control) and undesirable
(e.g. side effects and emergence of bacterial resis-
tance) effects of these drugs. For example, an antibi-
otic taken above the optimal dose may lead to an
increase in the side effects of the drug, whereas an
underdose may not eliminate the target species and
might yield bacterial tolerance to the drug. Normally,
the antibiotic protocols (e.g. dose and duration of
therapies) used in dentistry are extrapolations of
those recommended for medical infections. This
might result in erroneous prescriptions, especially for
the treatment of periodontal diseases, as a result of
certain unique features of these conditions that are
not normally observed in medical infections, such as
the microbial protection afforded by the biolm
structure and the large variation in the concentration
of the drugs in different sites of the oral cavity (174,
175, 194).
The lack of clear guidelines and a single protocol
for antibiotic use in periodontal treatment have gen-
erated great heterogeneity among the designs of the
randomized clinical trials, making the comparison of
the results of these studies a very difcult task. The
only exception seems to be the dose of amoxicillin,
which has been used in most studies at a dose of 500
mg three times daily (2, 40, 42, 55, 59, 85, 95, 119, 120,
122, 123, 130, 137139, 141, 146, 184, 212, 215, 221).
On the other hand, the ideal dose of metronidazole
for the treatment of periodontal infections has been
 Systemic antibiotics in periodontal therapy

more controversial as it has been administered three
times daily in a variety of different doses, such as 200/
250 mg (10, 16, 33, 40, 50, 66, 72, 85, 95, 112, 116, 118,
122, 123, 141, 142, 146, 166, 170, 212) and 400/500 mg
(2, 14, 15, 18, 19, 42, 55, 59, 130, 137139, 183, 184,
215, 221). Another important issue is the duration of
the treatment with metronidazole, amoxicillin or the
combination of both, which is also not completely
dened and normally varies from 7 (2, 16, 18, 19, 55,
59, 123, 141, 142, 146, 154, 166, 170, 214, 215, 221), to
8 (33, 183), 10 (10, 14, 15, 85, 95, 137, 212) or 14 (40,
42, 50, 66, 72, 130, 138, 139, 168, 184) days. When both
dose and duration of these systemic antibiotics are
taken into consideration, the variation of the study
protocols is even higher. Thus, with the data currently
available it is difcult to determine, for example, if
the benets achieved with 250 mg of metronidazole
administered for 14 days are comparable with those
obtained with a higher dose (e.g. 400 mg) adminis-
tered for fewer days (e.g. 7 days). The answers to
these questions are crucial because they are directly
associated with treatment effectiveness and patient
comfort. Let us consider a hypothetical situation in
which the two protocols outlined above would pro-
vide the same clinical benet with similar side effects.
In this case, the protocol using a higher dose

Table 16. Number of sites with probing depth 5, 6 and 7 mm at baseline and at 3 months post-treatment in 60
subjects with advanced periodontitis treated with scaling and root planing alone, or scaling and root planing combined
with 250 mg or 400 mg of metronidazole + 500 mg of amoxicillin for 7 or 14 days

Probing Time Treatment groups P*

depth point
7 days 14 days

Scaling and root Amoxicillin + Amoxicillin + Amoxicillin + Amoxicillin +

planing (n = 12) metronidazole metronidazole metronidazole metronidazole
250 mg (n = 12) 400 mg (n = 12) 250 mg (n = 12) 400 mg (n = 12)

5 mm Baseline 33.1  21.6a 35.7  22.5a 36.7  22.1a 32.1  24.2a 31.2  18.4a 0.943
3 months 17.1  14.0 A,b
11.2  12.3 b
11.4  8.2 b
9.8  8.2 B,b
6.3  9.9 B,b
0.001
6 mm Baseline 22.5  15.1 a
25.1  20.5 a
24.6  16.3 a
22.8  20.9 a
20.5  15.9 a
0.860
3 months 10.2  10.8 A,b
5.0  7.0 B,b
5.0  4.4 B,b
4.7  3.9 B,b
2.2  4.8 B,b
0.006
7 mm Baseline 11.7  9.3a 16.0  15.7a 13.9  11.4a 10.0  14.2a 11.4  9.4a 0.350
3 months 4.9  6.2 A,b
2.5  3.7 B,b
2.4  2.2 B,b
1.9  1.8 B,b
0.9  3.1 B,b
0.007
Values are given as mean  SD. *The signicance of differences among groups at each time point was assessed using the KruskalWallis and Dunns multiple com-
parison tests (different capital letters indicate signicant differences between pairs of groups). The signicance of differences between time points was determined
using the Wilcoxon test (different lower-case letters indicate signicant differences between time points).

Table 17. Changes in probing depth and clinical attachment between baseline and 3 months post-treatment in 60
subjects with advanced periodontitis treated with scaling and root planing alone, or scaling and root planing combined
with 250 mg or 400 mg of metronidazole + 500 mg of amoxicillin for 7 or 14 days

Baseline Time point Treatment groups P*

probing
depth 7 days 14 days

Scaling and root Amoxicillin + Amoxicillin + Amoxicillin + Amoxicillin +

planing (n = 12) metronidazole metronidazole metronidazole metronidazole
250 mg (n = 12) 400 mg (n = 12) 250 mg (n = 12) 400 mg (n = 12)

46 mm Probing depth 1.1  0.5A 1.5  0.4B 1.6  0.4B 1.7  0.3B 1.8  0.5B 0.010
reduction (mm)
Clinical attachment 0.6  0.6 1.0  0.7 1.0  0.7 1.0  0.4 1.1  0.5 0.335
gain (mm)
7 mm Probing depth 1.9  1.0A 3.3  1.0B 3.3  0.8B 3.5  0.9B 3.6  1.4B 0.006
reduction (mm)
Clinical attachment 1.3  1.0A 2.2  1.4 2.1  0.8 2.5  1.3B 2.5  1.2B 0.011
gain (mm)
Values are given as mean  SD. *The signicance of differences among groups at each time point was assessed using the KruskalWallis and Dunns multiple com-
parison tests (different letters indicate signicant differences between pairs of groups).

171
Feres et al.

7 days 14 days
SRP MTZ 250 mg MTZ 400 mg MTZ 250 mg MTZ 400 mg
Counts x105 0.0 12.3 24.6 36.9 49.1 0.0 12.3 24.6 36.9 49.1 0.0 12.3 24.6 36.9 49.1 0.0 12.3 24.6 36.9 49.1 0.0 12.3 24.6 36.9 49.1

A.gerencseriae
A.israelii Actinomyces
A.naeslundii
A.oris
A.odontolyticus *
Purple
V.parvulla
S.gordonii
S.intermedius Baseline
S.mitis Yellow 3 months
S.oralis
S.sanguinis
A. actinomycetemcomitans
C.gingivalis
C.ochracea Green
C.sputigena
E.corrodens
C.gracilis
*
C.rectus
C.showae * * **
E.nodatum
F.nucleatum.ssp.nucleatum ** ** *
** **
**
F.nucleatum.ssp.polymorphum
F.nucleatum.ssp.vincentii
F.periodonticum Orange * *
P.micra
P.intermedia ** *
**
P.nigrescens
S.constellatus **
T.forsythia *
P.gingivalis
** ** ** **
T.denticola Red
* ** ** **
E.saburreum
* ** * **
G.morbillorum
L.buccalis
P.acnes Others
P.melaninogenica
N.mucosa
S.anginosus
S.noxia
T.socranskii
*
* *
Fig. 12. Proles of mean counts (3105) of 40 taxa in subgin- tent of 40 species of bacteria. The species were ordered and
gival biolm samples taken from 60 subjects with advanced grouped according to the microbial complexes described by
periodontitis treated with scaling and root planing (SRP), Socransky et al. (193). The mean values for each species
alone or combined with 250 mg or 400 mg of metronida- were averaged within a subject and then across subjects in
zole (MTZ) + 500 mg of amoxicillin for 7 or 14 days at base- each group at each time point. The signicance of differ-
line and at 3 months post-treatment. Nine subgingival ences between time points was determined using the Wilco-
biolm samples were taken from each subject at each time xon test adjusted for multiple comparisons [Socransky et al.
point and were analyzed separately to determine their con- (199)] (*P < 0.05; **P < 0.01).

(400 mg), for a shorter period of time (7 days), would
be the most recommended because it could increase
patient adherence to treatment and minimize the
problems of bacterial resistance to drugs. The sys-
temic administration of antibiotics for long periods of
time is the main cause of the lack of patient compli-
ance (52).
In an attempt to improve the protocol for the
clinical use of metronidazole + amoxicillin, we
conducted the following double-blind, placebo-con-
trolled clinical trial. A group of nonsmoker subjects
with advanced periodontitis (generalized chronic
periodontitis) were randomly assigned to receive
scaling and root planing, either alone (control
group) or combined with 250 mg or 400 mg of met-
ronidazole three times daily + 500 mg of amoxicillin
three times daily, for either 7 or 14 days (total of
four test groups). Subjects were clinically monitored
at baseline and at 3 months post-therapy. No statis-
tically signicant differences were observed among
the ve groups at baseline (data not shown). The
mean probing depth and clinical attachment level of
the ve groups varied from 3.7 mm to 3.9 mm and
from 4.1 mm to 4.7 mm, respectively. Subjects
receiving systemic antibiotics at any dosage or dura-
tion exhibited generally better clinical results in
comparison with those treated with scaling and root
planing only (Tables 16 and 17). However, at
3 months post-therapy, only the two test groups
receiving systemic antibiotics for 14 days showed a
statistically signicant lower mean number of resid-
ual sites with probing depth 5 mm (n = 9.8 for
250 mg of metronidazole + 500 mg of amoxicillin;
and n = 6.3 for 400 mg of metronidazole + 500 mg
of amoxicillin) in comparison with the control group
(n = 17.1) (Table 16). In addition, subjects in these

172

two groups also presented the greatest gain in clini-
cal attachment at initially deep sites in comparison
with those treated with scaling and root planing
only (P < 0.05) (Table 17). In accordance with the
clinical changes, the most striking benecial changes
in the subgingival microbial composition were
observed in the two test groups receiving the
systemic antibiotics for 14 days (Figs 12 and 13).
Subjects in all antibiotic groups showed a statisti-
cally signicant reduction in the individual levels of
the three red complex pathogens (T. forsythia, P.
gingivalis and T. denticola) but the two groups with
the longer period of antibiotic administration
(14 days) also had a reduction in ve putative
pathogens from the orange complex, against one or
two species in the other three groups (Fig. 12). In
addition, at 3 months post-therapy, these two test
groups, but not those two taking the antibiotics for
7 days, showed statistically signicantly lower
residual mean proportions of red complex (5.7% for
250 mg of metronidazol; 5.1% for 400 mg of
A days antibiotic regimen were less evident.
16.0
Red complex
(T. forsythia, P. gingivalis and T. denticola)
12.0
Mean proportion (%)
8.0
4.0
0.0
SRP MTZ 250 mg MTZ 400 mg MTZ 250 mg
7 days
Fig. 13. Bar charts of the mean proportions of the three
red complex bacterial species (Tannerella forsythia, Por-
phyromonas gingivalis and Treponema denticola) in sub-
gingival biolm samples taken from 60 subjects with
advanced periodontitis treated with scaling and root plan-
ing (SRP) alone or combined with 250 mg or 400 mg of
metronidazole (MTZ) + 500 mg of amoxicillin for 7 or
14 days, at 3 months post-treatment. Nine subgingival
biolm samples were taken from each subject at each time
point and were analyzed separately to determine their
content of the three red complex species. The percentage
of DNA probe counts for each species was determined at
each site, then averaged within a subject and then across
subjects in each group. The mean proportion of each
species was summed in order to determine the proportion
of the red complex. The signicance of differences
among groups was determined using KruskalWallis and
Dunns multiple comparison tests (different letters indi-
cate signicant differences between pairs of groups,
P < 0.05).
Systemic antibiotics in periodontal therapy
metronidazole) in comparison with the control
group (15.5%) (Fig. 13). No statistically signicant
differences were observed for the clinical and micro-
biological parameters evaluated between the two
groups taking 250 or 400 mg of metronidazole for
7 days or between those taking 250 or 400 mg of
metronidazole for 14 days. However, within the 14-
days antibiotic regimen, there was a tendency
toward better results for the higher-dose subgroup
(400 mg), mainly for the number of residual sites
with probing depth 5 mm post-therapy. No statisti-
cally signicant differences were observed among
the four antibiotic groups for the individual adverse
effects reported.
In summary, these short-term preliminary data
suggest that the duration of the metronidazole +
amoxicillin intake interferes with treatment success.
The adjunctive use of these antibiotics for 14 days,
irrespective of the metronidazole dosage, offers
short-term clinical and microbiological benets over
scaling and root planing alone, in the treatment of
advanced periodontitis. The added benets of the 7-
In which phase of the mechanical
treatment should the antibiotic be
prescribed?
B Two different questions related to the ideal time for
B systemic antibiotic use in periodontal treatment
remain unanswered: (i) should the antibiotic(s) be
administered during the active phase of therapy or on
re-evaluation (i.e. 3 or 6 months after active treat-
ment); and (ii) should the antibiotic(s) be adminis-
tered on the rst or last day of the scaling and root
MTZ 400 mg
14 days
planing procedure?
Let us focus on the rst question: Should the anti-
biotic (s) be administered during the active phase of
therapy or on re-evaluation?. Two previous investiga-
tions one retrospective study (96) and a randomized
clinical trial (55) have addressed this question, and
the results of both studies suggested greater clinical
benets when metronidazole + amoxicillin were
prescribed at the initial phase of therapy than in the
re-evaluation period. This statement is in line with
the notion, already strengthened in this article, that a
rapid and striking reduction in the subgingival
microbiota would be necessary in order to obtain the
most benecial recolonization possible of the
recently scaled pockets. Milder perturbations might
not be enough to change the highly stable climax
community of the mature biolm (194, 198). As
recolonization is partially achieved at 3 months
173
Feres et al.
post-scaling and root planing there is a chance that
the antibiotic given at this stage would work almost
as a maintenance scaling. On the other hand, more
aggressive treatments applied at once, such as the
association of scaling and root planing and antibiotics
during the initial therapy, would have greater poten-
tial to create an entirely new and stable climax com-
munity, similar to that observed in health.
Two aspects associated with the presence of a more
intense inammatory process before the implemen-
tation of mechanical treatment also provide addi-
tional arguments for the antibiotic(s) prescription at
the initial phase of therapy: (i) the higher concentra-
tion of antibiotic delivered to the subgingival area as
a result of the increased levels of gingival crevicular
uid; and (ii) higher permeability of capillaries, which
may contribute to enhanced antibiotic uptake (96).
Hence, when the clinician makes the decision to
appraise the results of the initial treatment in order to
evaluate the need for prescribing a systemic
Fig. 14. Pie charts describing the mean proportions of
microbial complexes in subgingival biolm samples taken
from subjects who showed a very good clinical response at
3 months post-treatment (i.e. presented at most four sites
with probing depth 5 mm, the clinical endpoint for treat-
ment). Subjects were treated with scaling and root planing
(SRP) alone (n = 10) or combined with systemic antibiotics
(SRP+Antibiotics)(n=10); 400 mg of metronidazole or 400
mg of metronidazole + 500 mg of amoxicillin; three times
daily for 14 days. Nine subgingival biolm samples were
taken from each subject at baseline, and at 3 months and
1 year post-treatment, and were analyzed separately to
determine their content of the 40 species of bacteria listed
in Fig. 12. The percentage of DNA probe counts for each
species was determined at each site, then averaged within
174
antibiotic, he/she might naively incur some errors,
such as producing a series of mild and not totally
effective disturbances to biolm and preventing
higher concentrations of the drugs from reaching the
subgingival sites.
Another important point to consider when making
the decision to postpone the administration of antibi-
otics to the maintenance phase is related to some
limitations of our evaluation of treatment success.
Periodontists have always been challenged by the dif-
cult task of having to appraise the resolution of an
infection using clinical tools. Fortunately, good
parameters to assess clinical success have been estab-
lished by well-conducted and robust clinical studies,
such as the number of residual sites with probing
depth 5 mm (105, 132, 133), a parameter used in the
present article to determine the clinical endpoint for
treatment. However, no matter how good the clinical
parameter used to determine treatment success may
be, the clinical results alone may not provide all the
a subject and then across subjects in each group at each
time point. The mean proportion of each species was
summed in order to determine the proportion of each
complex. The colors represent the different complexes
described by Socransky et al. (193). The grey color repre-
sents species that did not fall into any complex, and
Actinomyces spp. are represented in blue. The signicance
of differences within each group over the course of the
study was assessed using Friedman and Dunns multiple
comparison tests (*P < 0.05 between baseline and
3 months and baseline and 1 year). The signicance of dif-
ferences between groups at each time point was deter-
mined using the MannWhitney U-test (different letters
indicate signicant differences between pairs of groups,
P < 0.05).
 Systemic antibiotics in periodontal therapy

information necessary to compare the effectiveness
of two therapies because similar clinical proles may
harbor distinct microbiota which, in turn, might
inuence the maintenance of the clinical results lon-
gitudinally. An example of this situation is presented
in Fig. 14, which presents the microbiological prole
of two groups of subjects who showed a very good
clinical response [at most four sites with probing
depth 5 mm (i.e. achieved the clinical endpoint for
treatment)] at 3 months after being treated with scal-
ing and root planing only (n = 10) or combined with
either metronidazole or metronidazole + amoxicillin
(n = 10). Slight differences in the composition of the
subgingival microbiota could be observed between
the two groups in the short term. Subjects who
received antibiotics had statistically signicant lower
mean proportions of red complex species (1.7%) and
a slightly higher proportion of Actinomyces species
(34%) compared with those treated with scaling and
root planing only (7.9% and 28.7%, respectively) at
3 months. Although these differences were not
sufcient to impact the clinical parameters in the
short term, they were accentuated over time, an effect
similar to that observed in subjects with moderate
disease (Fig. 9). At 1 year, subjects taking antibiotics
harbored 2% of red complex species and the mean
proportions of Actinomyces species reached 38.6%
compared with 11.5% and 20.8% observed in the scal-
ing and root planing group, respectively. This worsen-
ing in the microbial prole at 1 year impacted on the
clinical status, and 30% (three of 10) of the subjects
from the scaling and root planing group had an
increase in the number of sites with probing depth
5 mm, losing their status of low-risk prole for fur-
ther disease progression. On the other hand, all sub-
jects who took antibiotics at the beginning of the
treatment maintained the low risk prole up to 1 year
after treatment. These ndings reinforce the risk of
waiting for 3 or 6 months to take the decision of
prescribing antibiotics. However, a more precise rec-
ommendation of the best time to give the systemic
antibiotics will only be possible by conducting ran-
domized clinical trials specically designed to test
these two protocols directly.
The second question to be addressed concerning
the best time to administer the systemic antibiotics

Table 18. Changes in probing depth and clinical attachment between baseline and 3 months post-treatment in 29
subjects with advanced periodontitis treated with scaling and root planing combined with metronidazole + amoxicillin
starting with the rst session or immediately after the last session of scaling and root planing

Baseline probing Variables Treatment groups P*

depth
First session (n = 14) Last session (n = 15)

46 mm Probing depth reduction (mm) 1.6  0.4 1.7  0.4 0.258

Clinical attachment gain (mm) 1.5  0.4 1.5  0.5 0.226
7 mm Probing depth reduction (mm) 3.5  1.0 3.6  0.7 0.378
Clinical attachment gain (mm) 3.1  0.9 2.9  1.0 0.825
Values are given as mean  SD. *The signicance of differences between groups was assessed using the MannWhitney U-test.

Table 19. Number of sites with probing depth 5, 6 and 7 mm at baseline and at 3 months post-treatment in 29
subjects with advanced periodontitis treated with scaling and root planing combined with metronidazole + amoxicillin
starting at the rst session or immediately after the last session of scaling and root planing

Probing Time point Treatment groups P*

depth
First session (n = 14) Last session (n = 15)

5 mm Baseline 48.6  18.5 a

53.0  16.7a 0.783
3 months 6.0  5.2 b
5.2  4.4 b
0.456
6 mm Baseline 26.6  16.1 a
28.8  15.3 a
0.515
3 months 2.71  3.4 b
1.9  3.6 b
0.019
7 mm Baseline 14.2  11.5 a
16.1  10.6 a
0.732
3 months 1.0  2.0 b
1.0  2.2 b
0.149
Values are given as mean number of sites  SD. The signicance of differences between time points was determined using Wilcoxon test (different letters indicate
signicant differences between time points). *The signicance of differences between groups at each time point was assessed using the MannWhitney U-test.

175
Feres et al.

is: should the antibiotic (s) be administered at the
rst or at the last session of the scaling and root
planing procedure? No randomized clinical trial to
date has directly addressed this question, and in
theory there are biologically plausible explanations
to justify both protocols. One argument in favor of
administration of the systemic antibiotic at the end
of the mechanical treatment is to reduce the pro-
tective effect of the biolm before the drug is deliv-
ered to the site of infection. On the other hand,
delivering the antibiotic on the rst day of scaling
and root planing could have the same benets as
the administration of the antibiotics at the initial
treatment phase, which are: a more rapid and
striking reduction of the subgingival microbiota,
leading to a more benecial recolonization of the
treated sites (208) and the two positive aspects
mentioned above, associated with the intense
inammatory process present at the beginning of
treatment (i.e. higher antibiotic concentration as a
result of increased levels of gingival crevicular uid
and better antibiotic uptake owing to increased
capillary permeability). In order to address this
question directly we conducted a double-blind, pla-
cebo-controlled clinical trial with 29 subjects pre-
senting advanced periodontitis (generalized
aggressive periodontitis). The subjects were ran-
domly assigned to receive scaling and root planing
combined with metronidazole (400 mg, three times
daily for 14 days) + amoxicillin (500 mg, three
times daily for 14 days) starting with the rst ses-
sion or immediately after the last session of scaling

First session Immediately after last session

DNA probe counts (%) 0.0 4.2 8.5 12.7 17.0 0.0 4.2 8.5 12.7 17.0

A.gerencseriae
A.israelii ** Actinomyces
A.naeslundii
A.oris *
A.odontolyticus
V.parvulla Purple
S.gordonii
S.intermedius
S.mitis * Yellow **
S.oralis *
S.sanguinis
A.actinomycetemcomitans
Baseline
C.gingivalis
C.ochracea 3 months
C.sputigena * Green
E.corrodens **
C.gracilis *
C.rectus *
C.showae
E.nodatum **
F.nucleatum.ssp.nucleatum
F.nucleatum.ssp.polymorphum
F.nucleatum.ssp.vincentii
F.periodonticum Orange
P.micra
P.intermedia
P.nigrescens
S.constellatus
T.forsythia * *
P.gingivalis ** Red
**
T.denticola *
E.saburreum
G.morbillorum
L.buccalis
P.acnes Others
P.melaninogenica **
N.mucosa
S.anginosus
S.noxia
T.socranskii

Fig. 15. Proles of the mean proportions (%) of 40 taxa in
subgingival biolm samples taken from subjects with
advanced periodontitis treated with scaling and root plan-
ing combined with 400 mg of metronidazole (three times
daily for 14 days) + 500 mg of amoxicillin (three times
daily for 14 days), starting with the rst session (n = 14) or
immediately after the last session of scaling and root plan-
ing (n = 15); at baseline and at 3 months post-treatment.
Nine subgingival biolm samples were taken from each
subject at each time point and were analyzed separately to
determine their content of 40 species of bacteria. The spe-
cies were ordered and grouped according to the microbial
complexes described by Socransky et al. (193). The per-
centage of DNA probe counts for each species were deter-
mined at each site, averaged within a subject and then
across subjects in each group at each time point. The sig-
nicance of differences between time points was deter-
mined using the Wilcoxon test adjusted for multiple
comparisons [Socransky et al. (199)] (*P < 0.05;
**P < 0.01).

176

and root planing. Subjects received clinical and
microbiological monitoring at baseline and at
3 months post-scaling and root planing. At base-
line, no statistically signicant differences were
observed between groups for the clinical parame-
ters evaluated (P > 0.05, data not shown). The
mean probing depth and clinical attachment level
were, respectively, 3.8 mm and 2.7 mm in the con-
trol group and 3.9 mm and 2.7 mm in the test
group. Both antibiotic groups showed similar clini-
cal benets, including a reduction in the mean
probing depth and a gain in clinical attachment in
initially intermediate and deep sites (Table 18). In
addition, both groups exhibited fewer residual sites
with probing depth 5 mm at 3 months post-treat-
ment (antibiotic/rst scaling and root planing ses-
sion, n = 6, antibiotic/last scaling and root planing
session, n = 5.2, P > 0.05) (Table 19). The microbio-
logical effects of the two antibiotic protocols were
also quite similar (Fig. 15). In summary, no impor-
tant short-term differences were observed in the
clinical and microbiological parameters when
adjunctive metronidazole + amoxicillin treatment
started together or immediately after scaling and
root planing. However, randomized clinical trials
with larger sample sizes and with longer follow-up
periods would be very important to draw more
denitive conclusions about the use of these two
protocols.
Concluding thoughts
The concepts and the data discussed in this article
support the notion that treatment of periodontitis is
an ecological intervention and that clinical improve-
ment is associated with the suppression of periodon-
tal pathogens and recolonization of the biolm by
host-compatible species. This is not an easy goal to
achieve, especially when dealing with a highly orga-
nized climax biolm community, such as the mature
subgingival biolm associated with periodontitis. The
notion that pathogens are not restricted to deep peri-
odontal pockets, but might be present at high levels
and proportions in supragingival biolm, in healthy
sites and in all oral surfaces of individuals with peri-
odontitis complicates, even further, achievement of
the ecological change necessary to re-establish
periodontal health. In the light of this knowledge, it
seems quite unlikely that a mechanical treatment,
such as scaling and root planing, targeting only micro-
organisms present on the tooth surface, primarily in
moderate and deep pockets, would be the best treat-
Systemic antibiotics in periodontal therapy
ment to achieve this goal. Indeed, current evidence
suggests that the benecial changes in the subgingival
microbial composition achieved with scaling and root
planing can be considerably improved by the adjunc-
tive use of metronidazole or metronidazole + amoxi-
cillin, and these microbiological benets are
accompanied by important and sustained clinical
improvements. Considering the endpoint for treat-
ment used in the analyses presented in this article,
that is the presence of at most four sites with a
probing depth 5 mm, the number of subjects receiv-
ing scaling and root planing alone who could be
considered as successfully treated was always lower
than the number of those receiving adjunctive metro-
nidazole or metronidazole + amoxicillin. One of the
ndings with the greatest impact was that even sub-
jects with moderate periodontitis, or those who show
an excellent clinical short-term response to treatment,
would be at a lower risk for future disease progression
if they were treated with one of these antibiotic proto-
cols (Figs 9 and 14). An additional benet of metroni-
dazole + amoxicillin was observed in certain analyses/
studies (130, 184, Table 8 and Fig. 5). Besides the
overall trend of better clinical and microbiological
effects with the combination of both antibiotics, this
therapy yielded statistically signicant greater probing
depth reduction and clinical attachment gain in ini-
tially intermediate sites and an increase in the propor-
tions of the benecial Actinomyces species, in
comparison with metronidazole alone.
Metronidazole and amoxicillin seem to produce a
series of ecological benets. The rst is the effect of
these antibiotics in reducing the numbers of major
periodontal pathogens, such as that of metronidazole
on strict anaerobes and of metronidazole + amoxicil-
lin on A. actinomycetemcomitans (117, 211). Recent data
suggest that the striking inhibition of keystone patho-
gens would help to reverse the dysbiotic changes in
the subgingival microbiota improving the composi-
tion of the entire biolm community (73, 74). In
addition, the antibiotics could potentially control
periodontal pathogens present in the other oral sur-
faces, tissues, uids, epithelial cells and connective
tissue; and the broad-spectrum activity of amoxicillin
might potentiate the effect of scaling and root plan-
ing, leading to a more rapid and profound reduction
of the bacterial load in the subgingival space. Another
possible role of the antibiotics given at the initial
phase of periodontal therapy is to suppress the over-
growth of species, such as some proteolytic patho-
gens, that could benet from tissue damage during
scaling and root planing. This would diminish inam-
mation in the local tissues during healing, which, in
177
Feres et al.
turn, would hinder an increase in the proportions of
these same pathogens a common event in microbial
ecology, where colonizing species affect the habitat
and the habitat affects the colonizing organisms
(194). The combination of all the effects described
above would allow a recolonization of the recently
scaled pockets by the host-compatible initial coloniz-
ers, preventing the species of the red complex (and
possibly other pathogens) from recolonizing in high
numbers and proportions (38, 130, 138, 184) (Figs 49).
This new climax biolm community, which is more
compatible with health, is rather stable and difcult
to disturb, and would enable the long-term stability
of the periodontium (42, 50) (Tables 613).
Apparently, the notion that periodontitis can be,
most of the time, successfully treated by scaling and
root planing only should at least be questioned.
Despite that, scaling and root planing continues to be
considered as the gold standard treatment for peri-
odontal diseases. Why is this? One of the reasons is
the concept established in the 1990s that few, if any,
species would be affected by an antibiotic reaching
the subgingival space as a result of the biolm-con-
ferred antibiotic tolerance. This clearly is not the case,
as shown by all the data and studies described in this
article. Another possible reason for the delay in incor-
porating the antibiotics in the clinical practice relates
to the risks associated with the administration of
pharmacologically active agents, such as the develop-
ment of side effects. In addition, there is the general
fear that the administration of a systemic antibiotic
may lead to the emergence of new antibiotic-resis-
tant species, either by selecting for a mutation in the
organisms genome or by activating the expression of
previously existing antibiotic-resistance genes. In the
worst-case scenario, these genes could be transferred
within or between species, giving rise to a new bacte-
rial population resistant to the agent in question.
There seem to be no major side effects associated
with the intake of metronidazole and amoxicillin
(18, 42, 59, 130, 138, 179, 180, 184) and indirect data
suggest that increased proportions of antibiotic-
resistant species in the subgingival biolm appear to
occur largely as a result of selection of organisms that
were naturally resistant to the antibiotic before anti-
biotic administration (39, 66, 169). Assessing the
emergence of new antibiotic-resistant species is
more challenging. To conduct investigations speci-
cally designed to seek species that were previously
sensitive to the tested antibiotics that became resis-
tant to the drug after its administration is very dif-
cult, and unfortunately these data are not available in
the literature. Therefore, the recommendation of
178
antibiotics to treat periodontal infection should fol-
low the same principle used for the treatment of any
other infection, that is: the risks need to be clearly off-
set by benets to the patient benets that could not
be otherwise achieved or which would be achieved
with much greater difculty or risk by other means.
In this regard, both the reduced need for periodontal
surgery and the lower levels of pathogens associated
with the administration of systemic antibiotics, espe-
cially metronidazole+amoxicillin, need to be consid-
ered. In other words, the risks associated with
performing additional surgical procedures and with
the presence of higher levels of pathogenic bacteria in
the subgingival environment (for the patient`s local
and systemic health) should be included in the risk
benet evaluation.
Ultimately, the lack of clear guidelines and a single
protocol for the use of systemic antibiotics as
adjuncts to periodontal treatment, such as denition
of the ideal dose and duration, and the moment of
antibiotic administration, has also discouraged the
use of these agents in the periodontal practice. Some
of the data presented in the present article help to
(partially) answer some of these questions. Prelimin-
ary data suggest that starting the antibiotic intake at
the rst or at the last scaling and root planing session
does not signicantly impact the results of treatment
(Tables 18 and 19 and Fig. 15), but apparently the
intake of metronidazole+amoxicillin for 14 days
would lead to greater clinical and microbiological
improvements than their administration for 7 days,
with similar safety and tolerability (Tables 16 and 17,
Figs 12 and 13). These two nal statements need to
be conrmed by longitudinal data, longer than
3 months of follow-up. Moreover, possibly the antibi-
otics should be administered during the initial phase
of treatment, and the decision about whether or not
to prescribe these drugs should not be postponed to
the re-evaluation phase. This statement is based in
one randomized clinical trial (55), one retrospective
study (96) and on the biological concepts presented
in this article, but also needs to be conrmed by con-
trolled randomized clinical trials.
In summary, it is expected that all the recent
knowledge on the ecology of the periodontal infec-
tions and the additional and long-lasting benecial
effects of metronidazole and metronidazole+amoxi-
cillin in the treatment of periodontitis demonstrated
by well-conducted randomized clinical trials with 1
2 years of follow-up will nally lead to a change in
the periodontal treatment protocols, including the
use of these antibiotics during the active phase of
periodontal therapy.

Acknowledgment
This work was supported, in part, by research grants
5 R03 TW006269-02 DE-from the National Institute of
Dental and Craniofacial Research (NIDCR, USA);
2007/56413-0, 2007/55291-9, 2009/17677-8, 2010/
10384-2 and 2011/23034-2 from Sa ~o Paulo Research
Foundation (FAPESP, Brazil); and 311765/2006-8,
308308/2009-3, 308550/2009-9 and 306314/2010-0
from The National Council for Scientic and Techno-
logical Development (CNPq, Brazil).
References
1. Addy M, Langeroudi M. Comparison of the immediate
effects on the sub-gingival microora of acrylic strips con-
taining 40% chlorhexidine, metronidazole or tetracycline.
J Clin Periodontol 1984: 11: 379386.
2. Aimetti M, Romano F, Guzzi N, Carnevale G. Full-mouth
disinfection and systemic antimicrobial therapy in
generalized aggressive periodontitis: a randomized,
placebo-controlled trial. J Clin Periodontol 2012: 39: 284
294.
3. Ali RW, Lie T, Skaug N. Early effects of periodontal therapy
on the detection frequency of four putative periodontal
pathogens in adults. J Periodontol 1992: 63: 540547.
4. Ardila CM, Ferna ndez N, Guzma n IC. Antimicrobial sus-
ceptibility of moxioxacin against gram-negative enteric
rods from colombian patients with chronic periodontitis.
J Periodontol 2010: 81: 292299.
5. Ardila CM, Granada MI, Guzma n IC. Antibiotic resistance
of subgingival species in chronic periodontitis patients.
J Periodontal Res 2010: 45: 557563.
6. Ardila CM, Lo  pez MA, Guzma n IC. High resistance against
clindamycin, metronidazole and amoxicillin in Porphyro-
monas gingivalis and Aggregatibacter actinomycetemcomi-
tans isolates of periodontal disease. Med Oral Patol Oral
Cir Bucal 2010: 15: 947951.
7. Azmak N, Atilla G, Luoto H, Sorsa T. The effect of subgingi-
val controlled-release delivery of chlorhexidine chip on
clinical parameters and matrix metalloproteinase-8 levels
in gingival crevicular uid. J Periodontol 2002: 73: 608615.
8. Badersten A, Nilve us R, Egelberg J. Effect of nonsurgical
periodontal therapy. I. Moderately advanced periodontitis.
J Clin Periodontol 1981: 8: 5772.
9. Balmes P, Clerc G, Dupont B, Labram C, Pariente R, Poirier
R. Comparative study of azithromycin and amoxicillin/cla-
vulanic acid in the treatment of lower respiratory
tract infections. Eur J Clin Microbiol Infect Dis 1991: 10:
437439.
Saybak A, Yuva P. Analysis
10. Baltacioglu E, Aslan M, Sarac O,
of clinical results of systemic antimicrobials combined
with nonsurgical periodontal treatment for generalized
aggressive periodontitis: a pilot study. J Can Dent Assoc
2011: 77: b97.
11. Bonito AJ, Lux L, Lohr KN. Impact of local adjuncts to scal-
ing and root planing in periodontal disease therapy: a sys-
tematic review. J Periodontol 2005: 76: 12271236.
Systemic antibiotics in periodontal therapy
12. Bonta Y, Zambon JJ, Genco RJ, Neiders ME. Rapid identi-
cation of periodontal pathogens in subgingival plaque:
comparison of indirect immunouorescence microscopy
with bacterial culture for detection of Actinobacillus ac-
tinomycetemcomitans. J Dent Res 1985: 64: 793798.
13. Botero JE, Contreras A, Lafaurie G, Jaramillo A, Betancourt
M, Arce RM. Occurrence of periodontopathic and superin-
fecting bacteria in chronic and aggressive periodontitis
subjects in a Colombian population. J Periodontol 2007:
78: 696704.
14. Carvalho LH, DAvila GB, Lea ~o A, Goncalves C, Haffajee
AD, Socransky SS, Feres M. Scaling and root planing,
systemic metronidazole and professional plaque removal
in the treatment of chronic periodontitis in a Brazilian
population IImicrobiological results. J Clin Periodontol
2005: 32: 406411.
15. Carvalho LH, DAvila GB, Lea ~o A, Haffajee AD, Socransky
SS, Feres M. Scaling and root planing, systemic metronida-
zole and professional plaque removal in the treatment of
chronic periodontitis in a Brazilian population. I. Clinical
results.. J Clin Periodontol 2004: 31: 10701076.
16. Casarin RC, Peloso Ribeiro ED, Sallum EA, Nociti FH Jr,
Goncalves RB, Casati MZ. The combination of amoxicillin
and metronidazole improves clinical and microbiologic
results of one-stage, full-mouth, ultrasonic debridement in
aggressive periodontitis treatment. J Periodontol 2012: 83:
988998.
17. Choi BK, Park SH, Yoo YJ, Choi SH, Chai JK, Cho KS, Kim
CK. Detection of major putative periodontopathogens in
Korean advanced adult periodontitis patients using a
nucleic acid-based approach. J Periodontol 2000: 71: 1387
1394.
18. Cionca N, Giannopoulou C, Ugolotti G, Mombelli A.
Amoxicillin and metronidazole as an adjunct to full-mouth
scaling and root planing of chronic periodontitis. J Period-
ontol 2009: 80: 364371.
19. Cionca N, Giannopoulou C, Ugolotti G, Mombelli A.
Microbiologic testing and outcomes of full-mouth scaling
and root planing with or without amoxicillin/metronida-
zole in chronic periodontitis. J Periodontol 2010: 8: 1523.
20. Cobb CM. Clinical signicance of nonsurgical periodontal
therapy: an evidence-based perspective of scaling and root
planing. J Clin Periodontol 2002: 29(Suppl. 2): 616.
21. Colombo AP, Boches SK, Cotton SL, Goodson JM, Kent R,
Haffajee AD, Socransky SS, Hasturk H, Van Dyke TE,
Dewhirst F, Paster BJ. Comparisons of subgingival
microbial proles of refractory periodontitis, severe peri-
odontitis, and periodontal health using the human oral
microbe identication microarray. J Periodontol 2009: 80:
14211432.
22. Colombo AP, Teles RP, Torres MC, Rosale m W, Mendes
MC, Souto RM, Uzeda M. Effects of non-surgical mechani-
cal therapy on the subgingival microbiota of Brazilians
with untreated chronic periodontitis: 9-month results.
J Periodontol 2005: 76: 778784.
23. Colombo AP, Teles RP, Torres MC, Souto R, Rosale m WJ,
Mendes MC, Uzeda M. Subgingival microbiota of Brazilian
subjects with untreated chronic periodontitis. J Periodon-
tol 2002: 73: 360369.
24. Costerton JW, Stewart PS, Greenberg EP. Bacterial bio-
lms: a common cause of persistent infections. Science
1999: 21: 13181322.
179
Feres et al.
25. Cuesta AI, Jewtuchowicz V, Brusca MI, Nastri ML, Rosa
AC. Prevalence of Staphylococcus spp and Candida spp in
the oral cavity and periodontal pockets of periodontal dis-
ease patients. Acta Odontol Latinoam 2010: 23: 2026.
26. Cugini MA, Haffajee AD, Smith C, Kent RL Jr, Socransky
SS. The effect of scaling and root planing on the clinical
and microbiological parameters of periodontal diseases:
12-month results. J Clin Periodontol 2000: 27: 3036.
27. Dahl en G, Wikstro m M. Occurrence of enteric rods, staph-
ylococci and Candida in subgingival samples. Oral Micro-
biol Immunol 1995: 10: 4246.
28. Darby IB, Hodge PJ, Riggio MP, Kinane DF. Clinical and
microbiological effect of scaling and root planing in smo-
ker and non-smoker chronic and aggressive periodontitis
patients. J Clin Periodontol 2005: 32: 200206.
29. Dastoor SF, Travan S, Neiva RF, Rayburn LA, Giannobile
WV, Wang HL. Effect of adjunctive systemic azithromycin
with periodontal surgery in the treatment of chronic peri-
odontitis in smokers: a pilot study. J Periodontol 2007: 78:
18871896.
30. De Soete M, Mongardini C, Peuwels M, Haffajee A, Socran-
sky S, van Steenberghe D, Quirynen M. One-stage full--
mouth disinfection. Long-term microbiological results
analyzed by checkerboard DNADNA hybridization. J Peri-
odontol 2001: 72: 374382.
31. Doungudomdacha S, Rawlinson A, Walsh TF, Douglas CW.
Effect of nonsurgical periodontal treatment on clinical
parameters and the numbers of Porphyromonas gingivalis,
Prevotella intermedia and Actinobacillus actinomycetem-
comitans at adult periodontitis sites. J Clin Periodontol
2001: 28: 437445.
32. Dzink JL, Socransky SS, Ebersole JL, Frey DE. ELISA and
conventional techniques for identication of black-pig-
mented Bacteroides isolated from periodontal pockets. J
Perio Res 1983: 18: 369374.
33. Ehmke B, Moter A, Beikler T, Milian E, Flemmig TF.
Adjunctive antimicrobial therapy of periodontitis: long--
term effects on disease progression and oral colonization.
J Periodontol 2005: 76: 749759.
34. Emingil G, Han B, Ozdemir G, Tervahartiala T, Vural C,
Atilla G, Baylas H, Sorsa T. Effect of azithromycin, as an
adjunct to nonsurgical periodontal treatment, on microbi-
ological parameters and gingival crevicular uid biomar-
kers in generalized aggressive periodontitis. J Perio Res
2012: 47: 729739.
35. Faveri M, Feres M, Shibli JA, Hayacibara RF, Hayacibara
MM, de Figueiredo LC. Microbiota of the dorsum of the
tongue after plaque accumulation: an experimental study
in humans. J Periodontol 2006: 77: 15391546.
36. Faveri M, Figueiredo LC, Duarte PM, Mestnik MJ, Mayer
MP, Feres M. Microbiological prole of untreated subjects
with localized aggressive periodontitis. J Clin Periodontol
2009: 36: 739749.
37. Faveri M, Mayer MP, Feres M, de Figueiredo LC, Dewhirst
FE, Paster BJ. Microbiological diversity of generalized
aggressive periodontitis by 16S rRNA clonal analysis. Oral
Microbiol Immunol 2008: 23: 112118.
38. Feres M. Antibiotics in the treatment of periodontal dis-
eases: microbiological basis and clinical applications. Ann
R Australas Coll Dent Surg 2008: 19: 3744.
39. Feres M, Haffajee AD, Allard K, Som S, Goodson JM,
Socransky SS. Antibiotic resistance of subgingival species
180
during and after antibiotic therapy. J Clin Periodontol
2002: 29: 724735.
40. Feres M, Haffajee AD, Allard K, Som S, Socransky SS.
Change in subgingival microbial proles in adult peri-
odontitis subjects receiving either systemically-adminis-
tered amoxicillin or metronidazole. J Clin Periodontol
2001: 28: 597609.
41. Feres M, Haffajee AD, Goncalves C, Allard KA, Som S,
Smith C, Goodson JM, Socransky SS. Systemic doxycycline
administration in the treatment of periodontal infections
(II). Effect on antibiotic resistance of subgingival species.
J Clin Periodontol 1999: 26: 784792.
42. Feres M, Soares GMS, Mendes JAV, Silva MP, Faveri M,
Teles R, Socransky SS, Figueiredo LC. Metronidazole alone
or with amoxicillin as adjuncts to nonsurgical treatment of
chronic periodontitis: a 1-year double-blinded, pla-
cebo-controlled, randomized clinical trial. J Clin Periodon-
tol 2012: 39: 11491158.
43. Fujise O, Hamachi T, Inoue K, Miura M, Maeda K. Micro-
biological markers for prediction and assessment of treat-
ment outcome following non-surgical periodontal
therapy. J Periodontol 2002: 73: 12531259.
44. Gajardo M, Silva N, Gomez L, Leon R, Parra B, Contreras
A, Gamonal J. Prevalence of periodontopathic bacteria in
aggressive periodontitis patients in a Chilean population.
J Periodontol 2005: 76: 289294.
45. Gladue RP, Bright GM, Isaacson RE, Newborg MF. In vitro
and in vivo uptake of azithromycin by phagocytic cells:
possible mechanism of delivery and release at sites of
infection. Antimicrob Agents Chemother 1989: 33: 277282.
46. Gladue RP, Snider ME. Intracellular accumulation of azi-
thromycin by cultured human broblasts. Antimicrob
Agents Chemother 1990: 34: 10561060.
47. Gomi K, Yashima A, Nagano T, Kanazashi M, Maeda N,
Arai T. Effects of full-mouth scaling and root planing in
conjunction with systemically administered azithromycin.
J Periodontol 2007: 78: 422429.
48. Goncalves LFH, Fermiano D, Feres M, Figueiredo LC, Teles
FRP, Mayer MPA, Faveri M. Levels of Selenomonas species
in genereralized aggressive periodontitis. J Periodontal Res
2012: 47: 711718.
49. Goodson JM. Antimicrobial strategies for treatment of
periodontal diseases. Periodontol 2000 1994: 5: 142168.
50. Goodson JM, Haffajee AD, Socransky SS, Kent R, Teles R,
Hasturk H, Bogren A, Van Dyke T, Wennstrom J, Lindhe J.
Control of periodontal infections: a randomized controlled
trial I. The primary outcome attachment gain and pocket
depth reduction at treated sites. J Clin Periodontol 2012:
39: 525536.
51. Goodson JM, Hogan PE, Dunham SL. Clinical responses
following periodontal treatment by local drug delivery.
J Periodontol 1985: 56: 8187.
52. Greenberg RN. Overview of patient compliance with medi-
cation dosing: a literature review. Clin Ther 1984: 6: 592
599.
53. Greenstein G. Local drug delivery in the treatment of peri-
odontal diseases: assessing the clinical signicance of the
results. J Periodontol 2006: 77: 565578.
54. Griffen AL, Beall CJ, Campbell JH, Firestone ND, Kumar
PS, Yang ZK, Podar M, Leys EJ. Distinct and complex bac-
terial proles in human periodontitis and health revealed
by 16S pyrosequencing. ISME J 2012: 6: 11761185.

55. Grifths GS, Ayob R, Guerrero A, Nibali L, Suvan J, Moles
DR, Tonetti MS. Amoxicillin and metronidazole as an
adjunctive treatment in generalized aggressive periodonti-
tis at initial therapy or re-treatment: a randomized con-
trolled clinical trial. J Clin Periodontol 2011: 38: 4349.
56. Grisi DC, Salvador SL, Figueiredo LC, Souza SL, Novaes
AB, Grisi MF. Effect of a controlled-release chlorhexidine
chip on clinical and microbiological parameters of peri-
odontal syndrome. J Clin Periodontol 2002: 29: 875881.
57. Grossi SG, Goodson JM, Gunsolley JC, Otomo-Corgel J,
Bland PS, Doherty F, Comiskey J. Mechanical therapy with
adjunctive minocycline microspheres reduces red-com-
plex bacteria in smokers. J Periodontol 2007: 78: 1741
1750.
58. Guerrero A, Echeverra JJ, Tonetti MS. Incomplete adher-
ence to an adjunctive systemic antibiotic regimen
decreases clinical outcomes in generalized aggressive peri-
odontitis patients: a pilot retrospective study. J Clin
Periodontol 2007: 34: 897902.
59. Guerrero A, Grifths GS, Nibali L, Suvan J, Moles DR, Lau-
rell L, Tonetti MS. Adjunctive benets of systemic amoxi-
cillin and metronidazole in non-surgical treatment of
generalized aggressive periodontitis: a randomized pla-
cebo controlled clinical trial. J Clin Periodontol 2005: 32:
10961107.
60. Haas AN, de Castro GD, Moreno T, Susin C, Albandar JM,
Oppermann RV, Ro sing CK. Azithromycin as an adjunctive
treatment of aggressive periodontitis: 12-months random-
ized clinical trial. J Clin Periodontol 2008: 35: 696704.
61. Haas AN, Silva-Boghossian CM, Colombo AP, Susin C, Al-
bandar JM, Oppermann RV, Ro sing CK. Adjunctive azi-
thromycin in the treatment of aggressive periodontitis:
microbiological ndings of a 12-month randomized
clinical trial. J Dent 2012: 40: 556563.
62. Haffajee AD, Bogren A, Hasturk H, Feres M, Lopez NJ, Soc-
ransky SS. Subgingival microbiota of chronic periodontitis
subjects from different geographic locations. J Clin Period-
ontol 2004: 31: 9961002.
63. Haffajee AD, Cugini MA, Dibart S, Smith C, Kent RL Jr, Soc-
ransky SS. The effect of SRP on the clinical and microbio-
logical parameters of periodontal diseases. J Clin
Periodontol 1997: 24: 324334.
64. Haffajee AD, Dibart S, Kent RLJ, Socransky SS. Clinical and
microbiological changes associated with the use of 4
adjunctive systemically administered agents in the treat-
ment of periodontal infections. J Clin Periodontol 1995: 22:
618627.
65. Haffajee AD, Japlit M, Bogren A, Kent RL Jr, Goodson JM,
Socransky SS. Differences in the subgingival microbiota of
Swedish and USA subjects who were periodontally healthy
or exhibited minimal periodontal disease. J Clin Periodon-
tol 2005: 32: 3339.
66. Haffajee AD, Patel M, Socransky SS. Microbiological
changes associated with four different periodontal thera-
pies for the treatment of chronic periodontitis. Oral Micro-
biol Immunol 2008: 23: 148157.
67. Haffajee AD, Socransky SS, Gunsolley JC. Systemic
anti-infective periodontal therapy. A systematic review.
Ann Periodontol 2003: 8: 115181.
68. Haffajee AD, Socransky SS, Patel MR, Song X. Microbial
complexes in supragingival plaque. Oral Microbiol Immu-
nol 2008: 23: 196205.
Systemic antibiotics in periodontal therapy
69. Haffajee AD, Socransky SS. Relationship of cigarette smok-
ing to attachment level proles. J Clin Periodontol 2001:
28: 283295.
70. Haffajee AD, Teles RP, Socransky SS. Association of Eubac-
terium nodatum and Treponema denticola with human
periodontitis lesions. Oral Microbiol Immunol 2006: 21:
269282.
71. Haffajee AD, Teles RP, Socransky SS. The effect of peri-
odontal therapy on the composition of the subgingival
microbiota. Periodontol 2000 2006: 42: 219258.
72. Haffajee AD, Torresyap G, Socransky SS. Clinical changes
following four different periodontal therapies for the
treatment of chronic periodontitis: 1-year results. J Clin
Periodontol 2007: 34: 243253.
73. Hajishengallis G, Darveau RP, Curtis MA. The key-
stone-pathogen hypothesis. Nat Rev Microbiol 2012: 10:
717725.
74. Hajishengallis G, Lamont RJ. Beyond the red complex and
into more complexity: the polymicrobial synergy and dys-
biosis (PSD) model of periodontal disease etiology. Mol
Oral Microbiol 2012: 27: 409419.
75. Hallmon WW, Rees TD. Local anti-infective therapy:
mechanical and physical approaches. A systematic review.
Ann Periodontol 2003: 8: 99114.
76. Hamlet SM, Cullinan MP, Westerman B, Lindeman M, Bird
PS, Palmer J, Seymour GJ. Distribution of Actinobacillus
actinomycetemcomitans, Porphyromonas gingivalis and
Prevotella intermedia in an Australian population. J Clin
Periodontol 2001: 28: 11631171.
77. Han B, Emingil G, Ozdemir G, Tervahartiala T, Vural C,
Atilla G, Baylas H, Sorsa T. Azithromycin as an adjunctive
treatment of generalized severe chronic periodontitis: clin-
ical, microbiological and biochemical parameters. J Peri-
odontol 2012: 83: 14801491.
78. Hanes PJ, Purvis JP. Local anti-infective therapy: pharma-
cological agents. A systematic review. Ann Periodontol
2003: 8: 7998.
79. Haraszthy VI, Hariharan G, Tinoco EM, Cortelli JR, Lally
ET, Davis E, Zambon JJ. Evidence for the role of highly leu-
kotoxic Actinobacillus actinomycetemcomitans in the path-
ogenesis of localized juvenile and other forms of
early-onset periodontitis. J Periodontol 2000: 71: 912922.
80. Haubek D, Ennibi OK, Abdellaoui L, Benzarti N, Poulsen S.
Attachment loss in Moroccan early onset periodontitis
patients and infection with the JP2-type of Actinobacillus
actinomycetemcomitans. J Clin Periodontol 2002: 29: 657
660.
81. Heasman L, Stacey F, Preshaw PM, McCracken GI, Hep-
burn S, Heasman PA. The effect of smoking on periodontal
treatment response: a review of clinical evidence. J Clin
Periodontol 2006: 33: 241253.
82. Heasman PA, Heasman L, Stacey F, McCracken GI. Local
delivery of chlorhexidine gluconate (PerioChip) in peri-
odontal maintenance patients. J Clin Periodontol 2001: 28:
9095.
83. Heitz-Mayeld LJ, Trombelli L, Heitz F, Needleman I,
Moles D. A systematic review of the effect of surgical
debridement vs non-surgical debridement for the treat-
ment of chronic periodontitis. J Clin Periodontol 2002: 29:
92102.
84. Heller D, Silva-Boghossian CM, do Souto RM, Colombo
AP. Subgingival microbial proles of generalized
181
Feres et al.
aggressive and chronic periodontal diseases. Arch Oral
Biol 2012: 57: 973980.
85. Heller D, Varela VM, Silva-Senem MX, Torres MCB,
Feres-Filho EJ, Colombo APV. Impact of systemic antimicro-
bials combined to anti-infective mechanical debridement
on the microbiota of generalized aggressive periodontitis: a
6-month RCT. J Clin Periodontol 2011: 38: 355364.
86. Henry DC, Riffer E, Sokol WN, Chaudry NI, Swanson RN.
Randomized double-blind study comparing 3- and 6-day
regimens of azithromycin with a 10-day amoxicillin-clavul-
anate regimen for treatment of acute bacterial sinusitis.
Antimicrob Agents Chemother 2003: 47: 27702774.
87. Herrera D, Sanz M, Jepsen S, Needleman I, Roldan 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): 136159.
88. Hinrichs JE, Wolff LF, Pihlstrom BL, Schaffer EM, Liljemark
WF, Bandt CL. Effects of scaling and root planing on sub-
gingival microbial proportions standardized in terms of
their naturally occurring distribution. J Periodontol 1985:
56: 187194.
89. Hoepelman IM, Schneider MME. Azithromycin: the rst of
the tissue-selective azalides. Int J Antimicrob Agents 1995:
5: 145167.
90. Hung HC, Douglass CW. Meta-analysis of the effect of scal-
ing and root planing, surgical treatment and antibiotic
therapies on periodontal probing depth and attachment
loss. J Clin Periodontol 2002: 29: 975986.
91. Hussein I, Ranka M, Gilbert A, Davey K. Locally delivered
antimicrobials in the management of periodontitis: a criti-
cal review of the evidence for their use in practice. Dent
Update 2007: 34: 494496, 499502, 505506.
92. Ioannou I, Dimitriadis N, Papadimitriou K, Sakellari D,
Vouros I, Konstantinidis A. Hand instrumentation versus
ultrasonic debridement in the treatment of chronic peri-
odontitis: a randomized clinical and microbiological trial.
J Clin Periodontol 2009: 36: 132141.
93. Iwase M, Slots J, Berthold P, Taichman NS. Leukocidal
activity of staphylococci isolated from human periodontal
lesions. Oral Microbiol Immunol 1990: 5: 233236.
94. Johnson G, Guthmiller JM. The impact of cigarette smok-
ing on the periodontal disease and treatment. Periodontol
2000 2007: 14: 178194.
95. Kaner D, Bernimoulin JP, Hopfenmu ller W, Kleber BM,
Friedmann A. Controlled-delivery chlorhexidine chip ver-
sus amoxicillin/metronidazole as adjunctive antimicrobial
therapy for generalized aggressive periodontitis: a ran-
domized controlled clinical trial. J Clin Periodontol 2007:
34: 880891.
96. Kaner D, Christan C, Dietrich T, Bernimoulin JP, Kleber
BM, Friedmann A. Timing affects the clinical outcome of
adjunctive systemic antibiotic therapy for generalized
aggressive periodontitis. J Periodontol 2007: 78: 12011208.
97. Kim YC, Ko Y, Hong SD, Kim KY, Lee YH, Chae C, Choi Y.
Presence of Porphyromonas gingivalis and plasma cell
dominance in gingival tissues with periodontitis. Oral Dis
2010: 16: 375381.
98. Kinane DF, Chestnutt IG. Smoking and periodontal
disease. Crit Rev Oral Biol Med 2000: 11: 356365.
99. Kinane DF, Radvar M. A six-month comparison of three
periodontal local antimicrobial therapies in persistent
periodontal pockets. J Periodontol 1999: 70: 17.
182
100. Kno er GU, Purschwitz RE, Eick S, Pster W, Roedel M,
Jentsch HF. Microbiologic ndings 1 year after partial-
and full-mouth scaling in the treatment of moderate
chronic periodontitis. Quintessence Int 2011: 42: 107117.
101. Kolenbrander PE, Palmer RJ Jr, Rickard AH, Jakubovics NS,
Chalmers NI, Diaz PI. Bacterial interactions and succes-
sions during plaque development. Periodontol 2000 2006:
42: 4779.
102. Kumar PS, Griffen AL, Barton JA, Paster BJ, Moeschberger
ML, Leys EJ. New bacterial species associated with chronic
periodontitis. J Dent Res 2003: 82: 338344.
103. Kumar PS, Griffen AL, Moeschberger ML, Leys EJ. Identi-
cation of candidate periodontal pathogens and benecial
species by quantitative 16S clonal analysis. J Clin Microbiol
2005: 43: 39443955.
104. Labriola A, Needleman I, Moles DR. Systematic review of
the effect of smoking on nonsurgical periodontal therapy.
Periodontol 2000 2005: 37: 124137.
105. Lang NP, Tonetti MS. Periodontal risk assessment (PRA)
for patients in supportive periodontal therapy (SPT). Oral
Health Prev Dent 2003: 1: 716.
106. Lee HJ, Kang IK, Chung CP, Choi SM. The subgingival
microora and gingival crevicular uid cytokines in
refractory periodontitis. J Clin Periodontol 1995: 22:
885890.
107. Lepp PW, Brinig MM, Ouverney CC, Palm K, Armitage GC,
Relman DA. Methanogenic Archaea and human periodon-
tal disease. Proc Natl Acad Sci USA 2004: 20: 61766181.
108. Levy RM, Giannobile WV, Feres M, Haffajee AD, Smith C,
Socransky SS. The effect of apically repositioned ap sur-
gery on clinical parameters and the composition of the
subgingival microbiota: 12-month data. Int J Periodont
Rest Dent 2002: 22: 209219.
109. Li CL, Liu DL, Jiang YT, Zhou YB, Zhang MZ, Jiang W, Liu
B, Liang JP. Prevalence and molecular diversity of Archaea
in subgingival pockets of periodontitis patients. Oral
Microbiol Immunol 2009: 24: 343346.
110. Lindhe J, Liljenberg B. Treatment of localized juvenile
periodontitis. Results after 5 years. J Clin Periodontol 1984:
11: 399410.
111. Lindhe J, Liljenberg B, Adielson B, Borjesson I. The effect
of metronidazole therapy on human periodontal disease.
J Periodontal Res 1982: 17: 534536.
112. Loesche WJ, Giordano JR, Soehren S, Kaciroti N. The non-
surgical treatment of patients with periodontal disease:
results after 6.4 years. Gen Dent Curr Infect Dis 2005: 53:
298306.
113. Loesche WJ, Grossman NS. Periodontal disease as a spe-
cic, albeit chronic, infection: diagnosis and treatment.
Clin Microbiol Rev 2001: 14: 727752.
114. Loesche WJ, Grossman N, Giordano J. Metronidazole in
periodontitis (IV). The effect of patient compliance on
treatment parameters. J Clin Periodontol 1993: 20: 96104.
115. Loesche WJ, Schmidt E, Smith BA, Caffessee R, Stoll J. Met-
ronidazole therapy for periodontitis. J Periodontal Res
1987: 22: 224226.
116. Loesche WJ, Schmidt E, Smith BA, Morrison EC, Caffesse
R, Hujoel PP. Effects of metronidazole on periodontal
treatment needs. J Periodontol 1991: 62: 247257.
117. Loesche WJ, Syed SA, Laughon BE, Stoll J. The bacteriology
of acute necrotizing ulcerative gingivitis. J Periodontol
1982: 53: 223230.

118. Loesche WJ, Syed SA, Morrison EC, Kerry GA, Higgins T,
Stoll J. Metronidazole in periodontitis. I. Clinical and bac-
teriological results after 15 to 30 weeks. J Periodontol 1984:
55: 325335.
119. Lo pez NJ, Gamonal JA. Effects of metronidazole plus
amoxicillin in progressive untreated adult periodontitis:
results of a single 1-week course after 2 and 4 months.
J Periodontol 1998: 69: 12911298.
120. Lo pez NJ, Gamonal JA, Martinez B. Repeated metronida-
zole and amoxicillin treatment of periodontitis. A fol-
low-up study. J Periodontol 2000: 71: 7989.
121. Lo pez NJ, Mellado JC, Leighton GX. Occurrence of Actino-
bacillus actinomycetemcomitans, Porphyromonas gingiva-
lis and Prevotella intermedia in juvenile periodontitis.
J Clin Periodontol 1996: 23: 101105.
122. Lo pez NJ, Quintero A, Casanova PA, Ibieta CI, Baelum V,
Lo pez R. Effects of periodontal therapy on systemic mark-
ers of inammation in patients with metabolic syndrome:
a controlled clinical trial. J Periodontol 2012: 83: 267278.
123. Lo pez NJ, Socransky SS, Da Silva I, Japlit MR, Haffajee AD.
Effects of metronidazole plus amoxicillin as the only ther-
apy on the microbiological and clinical parameters of
untreated chronic periodontitis. J Clin Periodontol 2006:
33: 648660.
124. Lo pez NJ, Socransky SS, Da Silva I, Japlit MR, Haffajee AD.
Subgingival microbiota of chilean patients with chronic
periodontitis. J Periodontol 2004: 75: 717725.
125. Mager DL, Ximenez-Fyvie LA, Haffajee AD, Socransky SS.
Distribution of selected bacterial species on intraoral sur-
faces. J Clin Periodontol 2003: 30: 644654.
126. Mandell RL, Ebersole JL, Socransky SS. Clinical
immunologic and microbiologic features of active disease
sites in juvenile periodontitis. J Clin Periodontol 1987: 14:
534540.
127. Mandell RL, Socransky SS. Microbiological and clinical
effects of surgery plus doxycycline on juvenile periodonti-
tis. J Periodontol 1988: 59: 373379.
128. Marsh PD, Devine DA. How is the development of dental
biolms inuenced by the host? J Clin Periodontol 2011:
38(Suppl. 11): 2835.
129. Mascarenhas P, Gapski R, Al-Shammari K, Hill R, Soehren
S, Fenno JC, Giannobile WV, Wang HL. Clinical response
of azithromycin as an adjunct to non-surgical periodontal
therapy in smokers. J Periodontol 2005: 76: 426436.
130. Matarazzo F, Figueiredo LC, Cruz SE, Faveri M, Feres M.
Clinical and microbiological benets of systemic metroni-
dazole and amoxicillin in the treatment of smokers with
chronic periodontitis: a randomized placebo-controlled
study. J Clin Periodontol 2008: 35: 885896.
131. Matarazzo F, Ribeiro AC, Feres M, Faveri M, Mayer MP.
Diversity and quantitative analysis of Archaea in aggres-
sive periodontitis and periodontally healthy subjects. J
Clin Periodontol 2011: 38: 621627.
132. Matuliene G, Pjetursson BE, Salvi GE, Schmidlin K,
Bragger U, Zwahlen M, Lang NP. Inuence of residual
pockets on progression of periodontitis and tooth loss:
results after 11 years of maintenance. J Clin Periodontol
2008: 35: 685695.
133. Matuliene G, Studer R, Lang NP, Schmidlin K, Pjetursson
BE, Salvi GE, Bra gger U, Zwahlen M. Signicance of peri-
odontal risk assessment in the recurrence of periodontitis
and tooth loss. J Clin Periodontol 2010: 37: 191199.
Systemic antibiotics in periodontal therapy
134. Mayanagi G, Sato T, Shimauchi H, Takahashi N. Detection
frequency of periodontitis-associated bacteria by polymer-
ase chain reaction in subgingival and supragingival plaque
of periodontitis and healthy subjects. Oral Microbiol
Immunol 2004: 19: 379385.
135. McColl E, Patel K, Dahlen G, Tonetti M, Graziani F, Suvan
J, Laurell L. Supportive periodontal therapy using mechan-
ical instrumentation or 2% minocycline gel: a 12 month
randomized, controlled, single masked pilot study. J Clin
Periodontol 2006: 33: 141150.
136. Mdala I, Haffajee AD, Socransky SS, de Blasio BF, Thore-
sen M, Olsen I, Goodson JM. Multilevel analysis of clinical
parameters in chronic periodontitis after root planing/
scaling, surgery, and systemic and local antibiotics: 2-year
results. J Oral Microbiol 2012. Doi: 10.3402/jom.v4i0.
17535.
137. Mendonca AC, Santos VR, Ribeiro FV, Lima JA, Miranda
TS, Feres M, Duarte PM. Surgical and non-surgical therapy
with systemic antimicrobials for residual pockets in type 2
diabetics with chronic periodontitis: a pilot study. J Clin
Periodontol 2012: 39: 368376.
138. Mestnik MJ, Feres M, Figueiredo LC, Duarte PM, Lira EA,
Faveri M. Short-term benets of the adjunctive use of met-
ronidazole plus amoxicillin in the microbial prole and in
the clinical parameters of subjects with generalized
aggressive periodontitis. J Clin Periodontol 2010: 37: 353
365.
139. Mestnik MJ, Feres M, Figueiredo LC, Soares G, Teles RP,
Fermiano D, Duarte PM, Faveri M. The effects of adjunc-
tive metronidazole plus amoxicillin in the treatment of
generalized aggressive periodontitis: a 1-year dou-
ble-blinded, placebo-controlled, randomized clinical Trial.
J Clin Periodontol 2012: 39: 955961.
140. Meulman T, Casarin RC, Peruzzo DC, Giorgetti AP, Barba-
gallo A, Casati MZ, Sallum EA, Goncalves RB, Nociti FH Jr.
Impact of supragingival therapy on subgingival microbial
prole in smokers versus non-smokers with severe chronic
periodontitis. J Oral Microbiol 2012. Doi: 10.3402/jom.v4i0.
8640.
141. Moeintaghavi A, Talebi-ardakani MR, Haerian-ardakani A,
Zandi H, Taghipour S, Fallahzadeh H, Pakzad A, Fahami
N. Adjunctive effects of systemic amoxicillin and metroni-
dazole with scaling and root planing: a randomized, pla-
cebo controlled clinical trial. J Contemp Dent Pract 2007: 8:
5159.
142. Mombelli A, Brochut P, Plagnat D, Casagni F, Giannopou-
lou C. Enamel matrix proteins and systemic antibiotics as
adjuncts to non-surgical periodontal treatment: clinical
effects. J Clin Periodontol 2005: 32: 225230.
143. Mombelli A, Lehmann B, Tonetti M, Lang NP. Clinical
response to local delivery of tetracycline in relation to
overall and local periodontal conditions. J Clin Periodontol
1997: 24: 470477.
144. Mombelli A, Schmid B, Rutar A, Lang NP. Persistence pat-
terns of Porphyromonas gingivalis, Prevotella intermedia/
nigrescens, and Actinobacillus actinomycetemcomitans
after mechanical therapy of periodontal disease. J Period-
ontol 2000: 71: 1421.
145. Moore WE, Holdeman LV, Cato EP, Smibert RM,
Burmeister JA, Palcanis KG, Ranney RR. Comparative bac-
teriology of juvenile periodontitis. Infect Immun 1985: 48:
507519.
183
Feres et al.
146. Moreira RM, Feres-Filho EJ. Comparison between
full-mouth scaling and root planing and quadrant-wise
basic therapy of aggressive periodontitis: 6-month clinical
results. J Periodontol 2007: 78: 16831688.
147. Morillo JM, Lau L, Sanz M, Herrera D, Martin C, Silva A.
Quantitative real-time polymerase chain reaction based
on single copy gene sequence for detection of periodontal
pathogens. J Clin Periodontol 2004: 31: 10541060.
148. Mouzakiti E, Pepelassi E, Fanourakis G, Markopoulou C,
Tseleni-Balafouta S, Vrotsos I. Expression of MMPs and
TIMP-1 in smoker and nonsmoker chronic periodontitis
patients before and after periodontal treatment. J Peri-
odontal Res 2012: 47: 532542.
149. Newman MG, Socransky SS. Predominant cultivable
microbiota in periodontosis. J Periodontal Res 1977: 12:
120128.
150. Novak MJ, Polson AM, Adair SM. Tetracycline therapy in
patients with early juvenile periodontitis. J Periodontol
1988: 59: 366372.
151. Novak MJ, Stamatelakys C, Adair SM. Resolution of early
lesions of juvenile periodontitis with tetracycline therapy
alone: long-term observations of 4 cases. J Periodontol
1991: 62: 628633.
152. Oteo A, Herrera D, Figuero E, OConnor A, Gonza lez I,
Sanz M. Azithromycin as an adjunct to scaling and root
planing in the treatment of Porphyromonas gingiva-
lis-associated periodontitis: a pilot study. J Clin Periodon-
tol 2010: 37: 10051015.
153. Ouverney CC, Armitage GC, Relman DA. Single-Cell enu-
meration of an uncultivated TM7 subgroup in the human
subgingival crevice. Appl Eviron Microbiol 2003: 69: 6294
6298.
154. Pahkla ER, Koppel T, Naaber P, Saag M, Loivukene K. The
efcacy of non-surgical and systemic antibiotic treatment
on smoking and non-smoking periodontitis patients.
Stomatologija 2006: 8: 116121.
155. Palmer RM, Matthews JP, Wilson RF. Non-surgical peri-
odontal treatment with and without adjunctive metroni-
dazole in smokers and non-smokers. J Clin Periodontol
1999: 26: 158163.
156. Palmer RM, Wilson RF, Hasan AS, Scott DA. Mechanisms
of action of environmental factors tobacco smoking.
J Clin Periodontol 2005: 32: 180195.
157. Pavia M, Nobile CG, Angelillo IF. Meta-analysis of local tet-
racycline in treating chronic periodontitis. J Periodontol
2003: 74: 916932.
158. Pavia M, Nobile CG, Bianco A, Angelillo IF. Meta-analysis
of local metronidazole in the treatment of chronic peri-
odontitis. J Periodontol 2004: 75: 830838.
159. Pavicic MJ, van Winkelhoff AJ, de Graaff J. In vitro suscep-
tibilities of Actinobacillus actinomycetemcomitans to a
number of antimicrobial combinations. Antimicrob Agents
Chemother 1992: 36: 26342638.
160. Pavicic MJ, van Winkelhoff AJ, Douque  NH, Steures RW,
de Graaff J. Microbiological and clinical effects of metroni-
dazole and amoxicillin in Actinobacillus actinomycetem-
comitans-associated periodontitis. A 2-year evaluation.
J Clin Periodontol 1994: 21: 107112.
161. Pedrazzoli V, Kilian M, Karring T, Kirkegaard E. Effect of
surgical and non-surgical periodontal treatment on peri-
odontal status and subgingival microbiota. J Clin Period-
ontol 1991: 18: 598604.
184
162. Pihlstrom BL, McHugh RB, Oliphant TH, Ortiz-Campos C.
Comparison of surgical and nonsurgical treatment of peri-
odontal disease. A review of current studies and additional
results after 61/2 years. J Clin Periodontol 1983: 10:
524541.
163. Ramberg P, Rosling B, Serino G, Hellstro m MK, Socransky
SS, Lindhe J. The long-term effect of systemic tetracycline
used as an adjunct to non-surgical treatment of advanced
periodontitis. J Clin Periodontol 2001: 28: 446452.
164. Ramfjord SP, Caffesse RG, Morrison EC, Hill RW, Kerry GJ,
Appleberry EA, Nissle RR, Stults DL. Four modalities of
periodontal treatment compared over ve years. J Peri-
odontal Res 1987: 22: 222223.
165. Rams TE, Slots J. Local delivery of antimicrobial agents in
the periodontal pocket. Periodontol 2000 1996: 10: 139
159.
166. Ribeiro EP, Bittencourt S, Zanin IC, Bovi Ambrosano GM,
Sallum EA, Nociti FH, Goncalves RB, Casati MZ.
Full-mouth ultrasonic debridement associated with amox-
icillin and metronidazole in the treatment of severe
chronic periodontitis. J Periodontol 2009: 80: 12541264.
167. Riviere GR, Smith KS, Tzagaroulaki E, Kay SL, Zhu X, DeR-
ouen TA, Adams DF. Periodontal status and detection fre-
quency of bacteria at sites of periodontal health and
gingivitis. J Periodontol 1996: 67: 109115.
168. Rodrigues DC, Taba MJ, Novaes AB, Souza SL, Grisi MF.
Effect of non-surgical periodontal therapy on glycemic
control in patients with type 2 diabetes mellitus. J Period-
ontol 2003: 74: 13611377.
169. Rodrigues RMJ, Goncalves C, Souto R, Feres-Filho EJ, Uze-
da M, Colombo APV. Antibiotic resistance prole of the
subgingival microbiota following systemic or local tetracy-
cline therapy. J Clin Periodontol 2004: 31: 420427.
170. Rooney J, Wade WG, Sprague SV, Newcombe RG, Addy M.
Adjunctive effects to non-surgical periodontal therapy of
systemic metronidazole and amoxycillin alone and com-
bined. A placebo controlled study. J Clin Periodontol 2002:
29: 342350.
171. Rosalem W, Rescala B, Teles RP, Fischer RG, Gustafsson A,
Figueredo CM. Effect of non-surgical treatment on chronic
and aggressive periodontitis: clinical, immunologic, and
microbiologic ndings. J Periodontol 2011: 82: 979989.
172. Rudney JD, Chen R, Sedgewick GJ. Actinobacillus actino-
mycetemcomitans, Porphyromonas gingivalis, and Tanne-
rella forsythensis are components of a polymicrobial
intracellular ora within human buccal cells. J Dent Res
2005: 84: 5963.
173. Ryder MI. The inuence of smoking on host responses
in periodontal infections. Periodontol 2000 2007: 43: 267
277.
174. Sagan C, Salvador A, Dubreuil D, Poulet PP, Duffaut D,
Brumpt I. Simultaneous determination of metronidazole
and spiramycin I in human plasma, saliva and gingival
crevicular uid by LC-MS/MS. J Pharm Biomed Anal 2005:
38: 298306.
175. Sakellari D, Goodson JM, Kolokotronis A, Konstantinidis A.
Concentration of 3 tetracyclines in plasma, gingival crevice
uid and saliva. J Clin Periodontol 2000: 27: 5360.
176. Sakellari D, Ioannidis I, Antoniadou M, Slini T, Konstantin-
idis A. Clinical and microbiological effects of adjunctive,
locally delivered chlorhexidine on patients with chronic
periodontitis. J Int Acad Periodontol 2010: 12: 2026.

177. Sampaio E, Rocha M, Figueiredo LC, Faveri M, Duarte PM,
Gomes Lira EA, Feres M. Clinical and microbiological
effects of azithromycin in the treatment of generalized
chronic periodontitis: a randomized placebo-controlled
clinical trial. J Clin Periodontol 2011: 38: 838846.
178. Scho nwald S, Gunjaca M, Kolacny-Babic L, Car V, Gosev
M. Comparison of azithromycin and erythromycin in the
treatment of atypical pneumonias. J Antimicrob Chemo-
ther 1990: 25(Suppl. A): 123126.
179. Sgolastra F, Gatto R, Petrucci A, Monaco A. Effectiveness
of systemic amoxicillin/metronidazole as adjunctive ther-
apy to scaling and root planing in the treatment of chronic
periodontitis: a systematic review and meta-analysis.
J Periodontol 2012: 83: 12571269.
180. Sgolastra F, Petrucci A, Gatto R, Monaco A. Effectiveness
of systemic amoxicillin/metronidazole as an adjunctive
therapy to full-mouth scaling and root planing in the
treatment of aggressive periodontitis: a systematic review
and meta-analysis. J Periodontol 2012: 83: 731743.
181. Shibli JA, Melo L, Ferrari DS, Figueiredo LC, Faveri M,
Feres M. Composition of supra- and subgingival biolm of
subjects with healthy and diseased implants. Clin Oral
Implants Res 2008: 19: 975982.
182. Shiloah J, Patters MR, Dean JW, Bland P, Toledo G. The
survival rate of Actinobacillus actinomycetemcomitans,
Porphyromonas gingivalis, and Bacteroides forsythus fol-
lowing 4 randomized treatment modalities. J Periodontol
1997: 68: 720728.
183. Sigusch B, Beier M, Klinger G, Pster W, Glockmann E. A
2-step non-surgical procedure and systemic antibiotics in
the treatment of rapidly progressive periodontitis. J Peri-
odontol 2001: 72: 275283.
184. Silva MP, Feres M, Sirotto TA, Soares GM, Mendes JA, Fa-
veri M, Figueiredo LC. Clinical and microbiological bene-
ts 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: 828837.
185. Slots J. Human viruses in periodontitis. Periodontol 2000
2010: 53: 89110.
186. Slots J. Selection of antimicrobial agents in periodontal
therapy. J Periodontal Res 2002: 37: 389398.
187. Slots J. The predominant cultivable organisms in juvenile
periodontitis. Scand J Dent Res 1976: 84: 110.
188. Slots J, Feik D, Rams TE. Age and sex relationships of su-
perinfecting microorganisms in periodontitis patients.
Oral Microbiol Immunol 1990: 5: 305308.
189. Slots J, Mashimo P, Levine MJ, Genco RJ. Periodontal ther-
apy in humans. I. Microbiological and clinical effects of a
single course of periodontal scaling and root planing, and
of adjunctive tetracycline therapy. J Periodontol 1979: 50:
495509.
190. Slots J, Rams TE. Antibiotics in periodontal therapy:
advantages and disadvantages. J Clin Periodontol 1990: 17:
479493.
191. Slots J, Ting M. Systemic antibiotics in the treatment of
periodontal disease. Periodontol 2000 2002: 28: 106176.
192. Smith SR, Foyle DM, Daniels J, Joyston-Bechal S, Smales
FC, Sefton A, Williams J. A double-blind placebocontrolled
trial of azithromycin as an adjunct to non-surgical treat-
ment of periodontitis in adults: clinical results. J Clin Peri-
odontol 2002: 29: 5461.
Systemic antibiotics in periodontal therapy
193. Socransky SS, Haffajee AD, Cugini MA, Smith C, Kent RL
Jr. Microbial complexes in subgingival plaque. J Clin Peri-
odontol 1998: 25: 134144.
194. Socransky SS, Haffajee AD. Dental biolms: difcult thera-
peutic targets. Periodontol 2000 2002: 28: 255.
195. Socransky SS, Haffajee AD, Dzink JL, Hillman JD. Associa-
tions between microbial species in subgingival plaque
samples. Oral Microbiol Immunol 1988: 3: 17.
196. Socransky SS, Haffajee AD, Dzink JL. Relationship of sub-
gingival microbial complexes to clinical features at the
sampled sites. J Clin Periodontol 1988: 15: 440444.
197. Socransky SS, Haffajee AD. Evidence of bacterial etiology:
a historical perspective. Periodontol 2000 1994: 5: 725.
198. Socransky SS, Haffajee AD. Periodontal microbial ecology.
Periodontol 2000 2005: 38: 135187.
199. Socransky SS, Haffajee AD, Smith C, Dibart S. Relation of
counts of microbial species to clinical status at the sample
sites. J Clin Periodontol 1991: 18: 766775.
200. Socransky SS, Haffajee AD. The nature of periodontal dis-
eases. Ann Periodontol 1997: 2: 310.
201. Socransky SS, Haffajee AD, Ximenez-Fyvie LA, Feres M,
Mager D. Ecological considerations in the treatment of
Actinobacillus actinomycetemcomitans and Porphyromon-
as gingivalis periodontal infections. Periodontol 2000 1999:
20: 341362.
202. So der B, Nedlich U, Jin LJ. Longitudinal effect of non-sur-
gical treatment and systemic metronidazole for 1 week in
smokers and non-smokers with refractory periodontitis: a
5-year study. J Periodontol 1999: 70: 761771.
203. Somayaji BV, Jariwala U, Jayachandran P, Vidyalakshmi K,
Dudhani RV. Evaluation of antimicrobial efcacy and
release pattern of tetracycline and metronidazole using a
local delivery system. J Periodontol 1998: 69: 409413.
204. Soskolne WA, Heasman PA, Stabholz A, Smart GJ, Palmer
M, Flashner M, Newman HN. Sustained local delivery of
chlorhexidine in the treatment of periodontitis: a
multi-center study. J Periodontol 1997: 68: 3238.
205. Sun J, Song X, Kristiansen BE, Kjaereng A, Willems RJ, Erik-
sen HM, Sundsfjord A, Sollid JE. Occurrence, population
structure, and antimicrobial resistance of enterococci in
marginal and apical periodontitis. J Clin Microbiol 2009:
47: 22182225.
206. Teixeira SR, Mattarazo F, Feres M, Figueiredo LC, de Fa-
veri M, Simionato MR, Mayer MP. Quantication of Por-
phyromonas gingivalis and mA genotypes in smoker
chronic periodontitis. J Clin Periodontol 2009: 36: 482487.
207. Teles RP, Gursky LC, Faveri M, Rosa EA, Teles FR, Feres M,
Socransky SS, Haffajee AD. Relationships between subgin-
gival microbiota and GCF biomarkers in generalized
aggressive periodontitis. J Clin Periodontol 2010: 37: 313
323.
208. Teles RP, Haffajee AD, Socransky SS. Microbiological goals
of periodontal therapy. Periodontol 2000 2006: 42: 180
218.
209. Teles RP, Teles FR, Loesche WJ, Listgarten M, Fine D, Lind-
he J, Malament K, Haffajee AD. Rediscovering Sig Socran-
sky, the genius and his legacy. J Dent Res 2012: 91: 433
439.
210. van Winkelhoff AJ, Herrera Gonzales D, Winkel EG, Delle-
mijn-Kippuw N, Vandenbroucke-Grauls CM, Sanz M. Anti-
microbial resistance in the subgingival microora in
patients with adult periodontitis. A comparison between
185
Feres et al.
The Netherlands and Spain. J Clin Periodontol 2000: 27:
7986.
211. van Winkelhoff AJ, Rodenburg JP, Goene  RJ, Abbas F,
Winkel EG, de Graaff J. Metronidazole plus amoxycillin in
the treatment of Actinobacillus actinomycetemcomitans
associated periodontitis. J Clin Periodontol 1989: 16: 128
131.
212. Varela VM, Heller D, Silva-Senem MX, Torres MC, Co-
lombo AP, Feres-Filho EJ. Systemic antimicrobials adjunc-
tive to a repeated mechanical and antiseptic therapy for
aggressive periodontitis: a 6-month randomized con-
trolled trial. J Periodontol 2011: 82: 11211130.
213. Watanabe K, Frommel TO. Detection of Porphyromonas
gingivalis in oral plaque samples by use of the polymerase
chain reaction. J Dent Res 1993: 72: 10401044.
214. Winkel EG, van Winkelhoff AJ, Timmerman MF, van der
Velden U, van der Weijden GA. Amoxicillin plus metroni-
dazole in the treatment of adult periodontitis patients. A
double-blind placebo-controlled study. J Clin Periodontol
2001: 28: 296305.
215. Xajigeorgiou C, Sakellari D, Slini T, Baka A, Konstantinidis
A. Clinical and microbiological effects of different antimi-
crobials on generalized aggressive periodontitis. J Period-
ontol 2006: 33: 254264.
216. Ximenez-Fyvie LA, Almaguer-Flores A, Jacobo-Soto V,
Lara-Cordoba M, Sanchez-Vargas LO, Alcantara-Maruri E.
Description of the subgingival microbiota of periodontally
untreated Mexican subjects: chronic periodontitis and
periodontal health. J Periodontol 2006: 77: 460471.
217. Ximenez-Fyvie LA, Haffajee AD, Socransky SS. Compari-
son of the microbiota of supra- and subgingival plaque in
186
health and periodontitis. J Clin Periodontol 2000: 27: 648
657.
218. Xime nez-Fyvie LA, Haffajee AD, Socransky SS. Microbial
composition of supra- and subgingival plaque in subjects
with adult periodontitis. J Clin Periodontol 2000: 27: 722
732.
219. Yang HW, Asikainen S, Dogan B, Suda R, Lai CH. Relation-
ship of Actinobacillus actinomycetemcomitans serotype b
to aggressive periodontitis: frequency in pure cultured iso-
lates. J Periodontol 2004: 75: 592599.
220. Yashima A, Gomi k, Maeda N, Arai T. One-stage
full-mouth versus partial-mouth scaling and root planing
during the effective half-life of systemically administered
azithromycin. J Periodontol 2009: 80: 14061413.
221. Yek EC, Cintan S, Topcuoglu N, Kulekci G, Issever H, Kant-
arci A. Efcacy of amoxicillin and metronidazole combina-
tion for the management of generalized aggressive
periodontitis. J Periodontol 2010: 81: 964974.
222. Zambon JJ, Slots J, Genco RJ. Serology of oral Actinobacil-
lus actinomycetemcomitans and serotype distribution in
human periodontal disease. Infect Immun 1983: 41: 1927.
223. Zandbergen D, Slot DE, Cobb CM, Van der Weijden FA.
The clinical effect of scaling and root planing and the con-
comitant administration of systemic amoxicillin and met-
ronidazole: a systematic review. J Periodontol 2013: 84:
332351.
224. Zappa U, Reinking-Zappa M, Graf H, Gmu r R, Savitt E.
Comparison of serological and DNA probe analyses for
detection of suspected periodontal pathogens in subgingi-
val plaque samples. Arch Oral Biol 1990: 35(Suppl.): 161S
164S.