There is a tension in the modern periodontal that we do not speak enough. A clinical paradox. We have our primary enemy in the look: a pathogenic biofilm that destroys the structures that keep the teeth in place. And we have our main weapon: mechanical release. But when this is not enough, we reach the big weapons. Antibiotics. And here is the problem that keeps me at night: the tools we use to neutralize the infection can reproduce a more durable, more dangerous monster for the future.
A recent study in Msppere put a good spot on it [8]. The researchers examined patients’ dental plate before and after periodontal treatment – especially for scaling and root (SRP) in combination with systemic antibiotics. What they found was worrying. Treatment not only reduced bad bacteria. It significantly increases the prevalence of antibiotic -resistant genes (ARGS) on the plate that remained. It’s like winning a battle, but arming the enemy for the next war.
This is not just an academic experiment. This is happening daily to our operators. We write a scenario for doxycycline or metronidazole, hoping to give SRP a push [1]. Or we place minocycline microspheres directly in a persistent pocket, targeting bacteria locally [6]. And according to clinical guidelines, this can offer a “moderate benefit” [7]. But at what cost? We contribute to a global public health crisis of antibiotic resistance, we all try to save a few millimeters of periodontal adhesion.
It forces us to ask a fundamental question. Do we just manage symptoms or really solve the problem? The answer, I think, is complicated. Because the problem is not just bacteria. He is the host.
Return to Basics: The Biofilm Mechanical War
Before we lose in the discussion of antibiotics, let’s get back to what we know it works. The cornerstone of all. Escalation and root error. Srp.
Let’s be clear about what this is. It is not a “deep cleaning”. I hate this term. It sounds like something you do on your carpets. SRP is a therapeutic process. It is a mechanical and biological reinstatement for the root environment of the tooth. We go under the gumline to those periodontal pockets – the pathological space created by the disease – and the meticulous removal of the calculus (tartar) and the plaque that cover the root surfaces.
The section of escalation is a violent force. Removing the hardened deposits that host billions of bacteria. But the root plan is the refinement. We look at the root to remove bacterial toxins and create a surface that is less new -friendly and more welcoming for gums to reconnect. This is the interruption of organized chaos of Biofilm. We cannot sterilize the pocket and we should not try. The goal is to shift the underlying ecosystem from a state of illness (difficulty) back to a healthier, more balanced.
But here is the incredible truth: SRP is only half of the battle. Maybe less. The other half, the place that determines the long -term success, occurs at home. In the patient’s bathroom. Twice a day with a toothbrush, once a day with thread or distorted cleanser. It is a non -negotiable partnership. I can perform the most technically perfect SRP, but if the patient does not maintain meticulous oral hygiene, the pathogenic biofilm will return in full force within a few weeks.
That is why patient education is so critical. We have to go through “Brush and Floss More”. We have to explain why. Periodontitis is not just gum disease. It’s bone loss. Your Foundation, collapses [5]. And this collapsing institution does not only threaten your teeth. Opens a gate for years inflammation to enter your entire system, affecting the risk of diabetes, cardiovascular disease and perhaps even Alzheimer’s [2]. When patients understand it, toothbrush and thread become medical organs, not just cosmetic tools.
After the active phase of treatment, the work continues with periodontal maintenance every three to four months. It is not a “standard”. It’s not a simple varnish. It is a targeted review of areas that are at risk to keep biofilm under control. As a study put it, this usual follow -up is just as important as the original treatment itself for constant success [4].
When deep pockets insist: discussion of a larger hammer
So what happens when you’ve done everything right? You have performed a masterful SRP. Your patient has become a superstar of home care. But during reassessment, you still find deep pockets-5, 6, 7mm-that continue to bleed during detection. The numbers do not hit. This is the gray zone. This is where clinical discussions are heated.
We go back and do it again? Or are we escalating? This is where these complementary treatments return to the game. Systematic antibiotics [1]. Locally delivered agents [6]. Facations of 0.12% chlorhexidine. And this is where this risk-benefit calculation becomes very real. Is the few tenths of a pocket reduction that we could gain from a doxycycline course worth the risk of promoting resistance? For a systematically healthy patient with localized deep pockets, I am increasingly cautious. For a diabetic patient with generalized, persistent inflammation, calculation can change. Systematic impacts are too serious to ignore [2].
If non -surgical approaches really fail, we should consider surgery. This is not a failure, but a different tool for a different job. We can have traditional surgery, where we really cut the gum tissue to reduce the depth of the pocket, making the area easier for the patient to cleanse. Or, in the right conditions, we can attempt regenerative surgery – using membranes and bone cuttings to try to rebuild the bone and the link destroyed by the disease [4] [5]. These are powerful techniques, but they are invasive and not without their own dangers and restrictions.
And then there is the periphery. The world of “natural” treatments that patients always ask. Green tea extracts, herbal rinses and other herbal [3]. Some preliminary research shows that they may have some anti -inflammatory or antibacterial properties. But the items are thin. Very thin. Are they harmful? Probably not. Is it a replacement for SRP, meticulous care at home and proven treatments? Not even close. They should never be used as a substitute for treatments supported by decades of science.
This brings us back the full circle to the original dilemma. The future of periodontal is probably not in a stronger antibiotic or more exotic mouth. It is in a deeper understanding of the oral germ and finding smarter, more targeted ways to configure it without the side damage to the antimicrobial broad spectrum.
References
[1] Moja, L., Zanichelli, V., Mertz, D., Gandra, S., Cappello, B., Cooke, GS, Chuki, P., Harbarth, S., Pulcini, C., Mendelson, M. IMI, M., Elias, Paulin, S., Muller, A., … Loeb, M. (2024). Basic drugs and recommendations for first and second -choice antibiotics for the empirical treatment of clinical infections. Clinical Microbiology and infection: The official publication of the European Society of Clinical Microbiology and Infectious Diseases; 30 Suppl 2S1 -S51.
[2] Basic drugs and recommendations for first and second -choice antibiotics for the empirical treatment of clinical infections. Clinical Microbiology and infection: The official publication of the European Society of Clinical Microbiology and Infectious Diseases; 30 Suppl 2S1 -S51.
[3] Alsaleh, A., Kapila, A., Shahriar, I., & Kapila, YL (2021). The challenges and estimates of dental awareness of patients with cognitive disorders. Periodontology 2000; 87(1), 43-49.
[4] Laleman, I., & Teughels, W. (2020). New natural oral reports and toothpastes based on products to prevent periodontal diseases. Periodontology 2000; 84(1), 102-123.
[5] Kwon, T., Lamster, IB, & Levin, L. (2021). Current concepts in managing periodontitis. International Dental Magazine; 71(6), 462-476.
[6] Cobb, Cm, & Sottosanti, JS (2021). A re -evaluation of the escalation and root design. Periodontics newspaper; 92(10), 1370-1378.
[7] Smiley, CJ, Tracy, SL, ABT, E., Michalowicz, BS, John, MT, Gunsolley, J., Cobb, CM, Rossmann, J., Harrel, SK, Forrest, JL, Hujoel, PP, Noraian, KW, Greenwell, H. Frantsve-Hawley, J., Rossmann, C. & Hanson, N. (2015). Systematic review and meta-analysis of non-surgical treatment of chronic periodontitis by escalating and root design with or without additives. Journal of the American Dental Association (1939); 146(7), 508-24.E5.
[8] Kang, Y, Sun, B., Chen, Y, Lou, Y, Zheng, M., & Li, Z. (2021). Dental plaque resistors of periodontal health and illness and their changes after escalating and design root. mm -minded; 6(4), E0016221.
