There is much that I agree with in Dr. Bueltmann’s letter, especially his concluding sentence that "surgical and nonsurgical treatments are complementary and not mutually exclusive, and each has its place in achieving periodontal health."
Our differences would derive from the conceptual approach where we treat advanced forms of periodontal disease as an anaerobic infection, rather than as a nonspecific overgrowth of the bacteria on the tooth surfaces.
We defined individuals as having advanced forms of periodontal disease when our experienced clinicians, after a thorough clinical examination, decided that surgery and extraction of teeth were inevitable. We diagnosed an anaerobic infection by demonstrating an overgrowth of certain anaerobic species such as spirochetes, or species that possess the benzoyl-DL-arginine naphthylamide enzyme, in three or four of the plaques removed from the four most diseased teeth in the dentition.
These patients were then randomly assigned to two treatment groups that consisted of a scaling and root planing plus placebo group (which we regard as the standard of care and, accordingly, we referred to this group as our positive control group), and a test group that received scaling and root planing, plus the antibiotic regimen for one or two weeks.
Our findings from four double-blind studies indicate that patients who received the antibiotic, especially metronidazole, did significantly better than the positive control group (who received only scaling and root planing) in regard to probing depth reductions1–3 and reduction in the need for periodontal surgery.2–4
We regard scaling and root planing as an essential component of treatment, but it is not sufficient to restore patients to optimal periodontal health. In fact, these studies would indicate that in patients with advanced forms of periodontal disease, it is scientifically indefensible to offer them scaling and root planing without antimicrobial treatment in the presence of a diagnosable anaerobic infection. Other investigators report the same findings—for instance, the recent results with azithromycin.5
Dr. Bueltmann states that the AAP treatment guidelines stress "that periodontal health should be achieved in the least invasive, cost-effective manner." I completely agree with this statement, but note that the individuals who contact me do not hear this message from their periodontists. For example, consider the following e-mail: "I am a 28-year-old female diagnosed with two 8-millimeters-deep gum pockets. The rest of the pockets range from 2 to 6 mm. I have slight bone loss and gum recession. One periodontist said my case is rather hopeless and another one suggests gum surgery."
I have heard similar laments from other patients suggesting that the enlightened guidelines of the AAP are not being heeded by some periodontists.
I also agree with Dr. Bueltmann that one should not prescribe antibiotics "to all patients." And, indeed, this is why we established criteria for disease severity and the diagnosis of an anaerobic infection before we entered patients into our four double-blind studies.
But it is equally incorrect not to prescribe antibiotics at all. If periodontal disease is a specific, albeit chronic, infection, good medicine requires the judicious use of antimicrobial agents. Antibiotics in periodontology shouldn’t be restricted to pro-phylactic use during periodontal surgery, or to salvage a refractory case.
Our studies and those of others are providing the basis for the judicious management of periodontal infections using antimicrobial agents when anaerobic infections are diagnosed.
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