Ahuja A. Role of Antibiotics in Generalized Aggressive Periodontitis

Journal of Indian Society of Periodontology - Vol 16, Issue 3, Jul-Sep 2012 317
Review Article
Address for
correspondence:
Dr. Annapurna Ahuja,
Department of
Periodontics, Sudha
Rustagi College of Dental
Sciences and Research,
Faridabad, India.
E-mail: annapurna.ahuja@
yahoo.com
Submission: 19-04-2011
Accepted: 02-04-2012
Department of
Periodontics,
Sudha Rustagi College
of Dental Sciences and
Research,
1
Department
of Pedodontics and
Preventive Dentistry,
Manav Rachna Dental
College, Faridabad,
India
Role of antibiotics in generalized
aggressive periodontitis: A review of
clinical trials in humans
Annapurna Ahuja, C. S. Baiju, Vipin Ahuja
1
Abstract:
Background: It is well-recognized fact that periodontal diseases are caused by multifactorial etiologies, in which
microorganisms play an important role. An essential component of therapy is to eliminate or manage these
pathogens. This has been traditionally accomplished through mechanical means by scaling and root planning
which is ineffective in some of the aggressive periodontal diseases. These aggressive diseases involve particular
groups of microorganisms which are not eliminated by mechanical means; and they require anti-infective therapy,
which includes local and systemic antimicrobials. This approach of therapy is of interest to periodontist due to
the aforementioned shortcomings of conventional methods. Materials and Methods: A manual and electronic
search was made for human studies up to March 2011 that presented clinical and microbiological data for the
effcacy of a systemic antibiotics in generalized aggressive periodontitis along with scaling and root planning.
A systematic approach was followed by two independent reviewers and included eligibility criteria for study
inclusion, quality assessment, and determination of outcome measures, data extraction, data synthesis, and
drawing of conclusion. Results: Only three randomized controlled human trials qualifed, and they concluded
that both scaling and root planing (SRP) mono-therapy and SRP with antibiotics proves benefcial in improving
clinical and microbiological parameters in aggressive periodontitis. Better results were seen in SRP with antibiotic
groups as compared with SRP alone. Conclusion: Because of the insuffcient quantity and heterogenecity of
studies, no adequate evidence could be gathered to use the benefcial effects of these antibiotics along with
SRP in aggressive periodontitis compared with SRP alone.
Key words:
Amoxicillin, generalized aggressive periodontitis, metronidazole, root planning, scaling
INTRODUCTION
I
t is a well-established fact that various
periodontal diseases are caused by bacterial
infections. Over the time, this microbial
plaque becomes more complex, so systemic
administration of antibiotics may be necessary
adjunct in controlling bacterial infections because
bacteria can invade periodontal tissues, making
mechanical therapy alone sometimes ineffective.
[1]

Although oral bacteria are susceptible to many
antibiotics, no single antibiotic at concentration
achieved in body fluids inhibit all putative
periodontal pathogens.
[2]
Indeed, a combination
of antibiotics may be necessary to eliminate
all putative pathogens from some periodontal
pockets;
[3]
it has been suggested that antibiotic
strength of 500 times greater than the usual
therapeutic dosage is needed to be effective
against bacteria arranged in bioflms.
[4]
Therefore,
it is logical to treat periodontal pockets by
mechanical disruption of the subgingival plaque
along with antibiotics. Systemic antibiotic
therapy combined with mechanical therapy
appears valuable in the treatment of recalcitrant
periodontal infections and localized aggressive
periodontitis (LAP) infections.
[5]
Rams and Slots
reviewed combination therapy using systemic
metronidazole (MTZ) along with amoxicillin
(AMX); this combination provides excellent
elimination of many organisms in adult and
LAP.
[6]
These drugs have additive effects
regarding suppression of microfora involved
in aggressive periodontitis. Thus, this review
discusses the role of scaling and root planing
(SRP) with or without antibiotics (AMX and
MTZ) in generalized aggressive periodontitis.
MATERIALS AND METHODS
Rationale
This review evaluates literature-based evidence
in an effort to determine the effcacy of currently
available systemic anti-infective agents, with
or without conventional SRP, in controlling
generalized aggressive periodontitis.
Focused question
The question addressed in this systematic review
was: In patients with generalized aggressive
periodontitis, what is the effect of systemic
antibiotics with scaling and root planning
compared to scaling and root planning alone, on
clinical and microbiological parameters.
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Ahuja, et al.: Adjunctive antibiotics Review of clinical trials
318 Journal of Indian Society of Periodontology - Vol 16, Issue 3, Jul-Sep 2012
4. Exclusion of patients with syndromes, pregnant, and
lactating mothers
5. Dosage and duration of drug
6. Toxicity/side effects evaluation of drugs
7. Sample size adequacy
Secondary quality criteria
1. Publication in peer-reviewed journal
2. Statement of compliance with regulatory requirements
3. Statement regarding possible conficts of interest. Each
quality criteria carried a score of one point for a possible
total of 10 points. Studies were graded as high quality = all
primary and secondary criteria were met. High moderate
quality->4 and<8 primary criteria and all secondary criteria
were met. Low moderate quality=>4 primary criteria
were met and 1 secondary criteria were not met; Poor
quality =4 primary criteria and all secondary criteria were
met. Very poor quality =4 primary criteria were met and
1 secondary criteria were not met.
RESULTS OF THREE INCLUDED STUDIES
Study selection and description: The MEDLINE and CENTRAL
literature searches resulted in 497 hits [Figure 1]. After the frst
selection step based on the title of the collected studies, 63 articles
were included for further analysis. The second step based on the
abstract screening resulted in 12 studies. From these studies,
three studies which completely fulflled the inclusion criteria
were selected. Nine studies were excluded at the last step, and
the reason for exclusion is presented in Table 1. The articles that
remained after the third selection (n = 3) are presented in Table 2.
Of these selected studies, one of these articles
[8]
assessed the
effects of AMX and MTZ with or without SRP in generalized
aggressive periodontitis, both clinically and microbiologically.
Subjects received systemic AMX (500 mg) + MTZ (250 mg) or
placebo, T.I.D. for 10 days. It was randomized, double-blinded,
placebo-controlled clinical trial for 6-month duration on 31
study population. In the second article,
[9]
patients received full-
mouth disinfection followed by staged SRP with or without
systemic antimicrobials AMX (500 mg ) + MTZ (250 mg) TID for
10 days. It was randomized, double-blinded, placebo-controlled
clinical trial for 6-month duration on 35 study population.
Search protocol
Data sources and search strategies
A search of MEDLINE, the Cochrane central trials register,
and web of science was conducted up to March 2011. The
review and all associated searches were confned to studies
published in English language. The MEDLINE and Cochrane
Library database were searched from 1950 till March 2011 using
the following Medical subject headings (MeSH): Aggressive
Periodontitis, Juvenile periodontitis, MTZ and AMX, scaling,
and root planning. Following completion of MEDLINE- and
Cochrane-controlled trials registry searches and web of science,
a supplementary search was conducted in each of this database
to include systemic MTZ and AMX with or without SRP, to
assure consistency with the study protocol. A total of 497
studies [Figure 1] were identifed addressing the use of MTZ
and AMX systemically in generalized aggressive periodontitis.
The studies were examined by 2 independent reviewers (AA,
CSB) to select studies relevant to the specifc question posed in
this review. Based on the study titles and abstracts, we selected
four studies which fulflled the inclusion criteria.
Inclusion criteria
1. Types of studies included were randomized, double-
blinded, placebo-controlled clinical trials of 6-month
duration on human beings
2. Publication in peer-reviewed international journals
published in English
3. Studies with clearly stated objectives of the research and/
or hypothesis to be tested
4. Required therapeutic interventions were (1) SRP (2) Systemic
antimicrobial therapy with SRP 3) Systemic antimicrobials
alone in patients with generalized aggressive periodontitis
Exclusion criteria
The studies which do not fulfll the inclusion criteria, non-
randomized clinical trials without placebo-controlled trials,
case reports, and split mouth designs were excluded.
Clinical patient outcome
The primary outcome measured included changes in probing
depth, clinical attachment level, Bleeding On Probing.
Surrogate secondary outcome measures included change in
subgingival microbial fora.
Data collection and analysis
Initially, titles and abstracts of studies identified by the
previously described search strategies were screened
independently by two reviewers (AA and CSB) to determine
if they should be included in the review. Selected studies were
independently reviewed by the reviewers using the criteria
defned above. Study selection criteria were applied to a subset
of relevant studies in order to calibrate the reviewers and to
offer practical application of the selection criteria.
Quality assessment and ranking of selected studies
The methodology quality of the studies was evaluated on the
basis of modifcations made in CAMARADES criteria.
[7]
Primary quality criteria
1. Clear objectives and methodology of the proposed study
2. Randomization to treatment or control
3. Masked assessment of outcome
Publications included in this
''best evidence paper'' N=3
Publications excluded on the
basis of full text evaluation N=9
Potentially relevent publications retrieved
for more detailed evaluation N=12
Potentially relevent publications
retrieved for further evaluation N=63
Publication excluded on the basis
of title evaluation N=434
Potentially relevent publications
identified N=497
Figure 1: Search strategy
Table 1: Abstracts excluded after text screening for not fulflling inclusion criteria n=9
Reference Patient group Study type level of
evidence
Methods Key results Comments
Zafropoulos,
et al.
[11]
N=1 patient
with GAP
Nonrandomized controlled
study/case report of 6.7-
year follow-up
Supragingival plaque
control and three
appointments of SRP,
MTZ +AMX for one
week, followed 10
weeks later by MTZ
+AMX /clavulanate for
one week
Antimicrobial and
mechanical treatment
resulted in eradication of
all periopathogens and
signifcantly improved all
clinical parameters
Twenty-four months later,
a relapse of GAP was
diagnosed and all teeth
had to be extracted
Yek, et al.
[12]
N=28 patients
with GAP
6 months nonrandomized
controlled study
Test gp (N=12) AMX +
MTZ combination and
SRP. control group
(N=16) received SRP
alone
All clinical parameters
improved signifcantly
compared to baseline
9 (P<0.05) in both
groups. There was a
statistically signifcant
reduction of pockets and
clinical attachment gain
in the combined group
(P<0.05). Total counts of
bacteria also decreased
signifcantly at 3 and 6
months in both groups
(P<0.05). T. denticola
showed a continuous
decrease over 6 months
in the test group, whereas
no change was seen in
the control group beyond
3 months. P. gingivalis
decreased signifcantly
at 3 months (P<0.05),
whereas T. forsythia
was the only pathogen
decreased below
detection limits by the
combination therapy with
a signifcant difference
compared to the control
group (P<0.05)
Combined AMX and
MTZ use as an adjunct
to SRP leads to better
clinical healing compared
to mechanical treatment
alone
Kaner D
[13]
N=36 patients
with GAP
controlled study
SRP and randomly with
either placement of CHX
(chlorhexidine) chips or
systemic AMX/MTZ
CAL, PD, BOP,
and exudation were
signifcantly reduced in
both the groups after 3
months. In the CHX chip
group, PD signifcantly
increased again between
3 and 6 months. Finally,
AMX/MTZ patients
presented signifcantly
more CAL gain, PD
reduction and less in
the CHX chip group, PD
signifcantly increased
again between 3 and 6
months. Finally, AMX/
MTZdazole patients
presented signifcantly
more CAL gain, PD
reduction and less BOP
In frst-line nonsurgical
therapy for GAP, SRP plus
adjunctive systemic AMX/
MTZ was more effcacious
in clinically relevant
measures of outcome
than SRP plus adjunctive
placement of CHX chips.
Guerrero,
et al.
[14]
N=18 patients
with GAP
controlled study
Full-mouth nonsurgical
periodontal treatment
and an adjunctive
course of systemic
antibiotics AMX 500
(mg) + and 500 (mg)
MTZ three times a day
for 7 days.
In deep pockets (>or =
7 mm), the difference
between an adherent
and nonadherent/partially
adherent subject was
0.9 mm (95%CI 0.1,
1.7 mm, P=0.027) in PPD
reduction and
Of 18 patient, only 11
subjects (61.1%) reported
full adherence to the
medication Prescribed.
Within the limits of this
design, these data suggest
that incomplete adherence
to a 7-day adjunctive
Contd
Table 1: Continued
evidence
0.8 mm (95% CI -0.2,1.9,
P=0.129) in CAL gain at
2 months. In moderate
pockets (4-6 mm), this
difference was smaller in
magnitude: 0.4 mm (95%
CI 0.1, 0.9 mm, P=0.036)
in PPD reduction and
0.2 mm (95% CI -0.3,
0.9 mm, P=0.332) in CAL
gain
course of systemic MTZ
and AMX is associated
with decreased clinical
outcomes in subjects with
GAP
Kaner
[15]
N=34 patients
with GAP
controlled study
Cohort A (17 patients;
36 +/- 5 years of age)
received systemic AMX/
MTZ immediately after
SRP (immediate) Cohort
B (17 patients; 36 +/- 4
years of age) received
the same regimen 3
months after SRP (late)
Immediate antibiotic
therapy produced
signifcantly higher
initial changes (0 to 3
months) in PD and RAL
(Relative attachment
level). Late antibiotic
therapy at 3 months
resulted in additional
signifcant improvements
in all clinical parameters
between 3 and 6 months.
In initially deep sites
(baseline PD >6 mm),
improvements in PD
and RAL over 6 months
were signifcantly higher
with immediate antibiotic
therapy compared to late
antibiotic therapy
Within the limits of a
retrospective analysis,
these fndings indicate that
administration of AMX/MTZ
immediately after initial
SRP provides more PD
reduction and RAL gain
in initially deep sites than
late administration at SPT
with reinstrumentation after
3 months
Xajigeorgiou,
et al.
[16]
N= 43 patients
with GAP
controlled study
Subjects are divided into
four groups. Six weeks
after SRP, groups 1-3
received adjunctive
MTZ+AMX Doxy cycline
(DOXY) and MTZ
respectively, and group
4 acted as control.
All treatment resulted in
improvement of clinical
parameters P>0.05.
systemic administration
of MTZ+AMX or MTZ
resulted in statistically
signifcant greater
reduction of the proportion
of sites>6 mm than SRP
(z-test, P< 0.05). These
antimicrobials yielded a
signifcant effect on levels
of important periodontal
pathogens for 6 months
Adjunctive MTZ+AMX
or MTZ alone (when A.
actinomycetemcomitans
is not involved) is effective
in deep pockets of GAP
patients
VanWinkelhoff,
et al.
[17]
Total N=22
N=11
LAPN=11GAP
9-11 months
nonrandomized controlled
study
Mechanical subgingival
debridement in
combination with
MTZ+AMX
With one exception,
clinical improvements
were observed in all
patients, resulting in
reduced PPD as well as
in a signifcant reduction
in bleeding on probing.
Reexamination of 16
patients after 9-11
months revealed that A.
was still undetectable
and further clinical
Improvement was
observed
Combination of MTZ+AMX
is a valuable adjunct to
mechanical therapy in A.
associated periodontal
infections
Griffths, et al.
[18]
N=41 patients
with GAP
6-8 months
nonrandomized controlled
study
Thirty-eight of
41 subjects, from the
initial 6-month trial,
completed the second
phase, retreatment of
sites with remaining
Patients who received
antibiotics at initial therapy
showed statistically
signifcant improvement
in PD reduction and in the
percentage of sites
Patients who received
antibiotics at initial therapy
showed statistically
signifcant improvement in
PD reduction and in the %
of sites improving
Contd
Table 1: Continued
evidence
pockets 5 mm. Subjects
on placebo in phase
one received adjunctive
antibiotics for 7 days
improving above clinically
relevant thresholds,
compared with patients
who received antibiotics
at re-treatment. In deep
pockets (7 mm), the
mean difference was
0.9 mm (P = 0.003) and
in moderate pockets
(4-6 mm), it was 0.4 mm
(P=0.036). For pockets
converting from 5 to
4 mm, this was 83%
compared with 67%
(P = 0.041) and pockets
converting from 4 to 3 mm
was 63% compared with
49% (P=0.297)
above clinically relevant
thresholds
Feres, et al.
[19]
N=30 patients
With GAP
A randomized double-
blind, placebo-controlled
clinical trial but of 3-month
duration
30 subjects received
SRP alone or combined
with MTZ (400 mg 3/
day) and AMX (500 g 3/
day) for 14 days
Subjects receiving MTZ
and AMX showed the
greatest improvements in
the mean full mouth PD
and CAL and at initially
intermediate and deep
sites. In the MTZ+AMX
group, which showed the
lowest proportions of the
red complex as well as a
signifcant decrease in the
proportions of the orange
complex after treatment.
Subjects with GAgP
signifcantly beneft from
the adjunctive use of MTZ
and AMX. The short-
term advantages are
observed in the clinical and
microbiological parameters
SRP - Scaling and root planing; AMX - Amoxicillin; MTZ - Metronidazole; BOP - Bleeding on probing; GAP Generalised aggressive periodontitis; PPD Probing
pocket depth
And, in the third study
[10]
included in this systematic review,
full-mouth non-surgical periodontal treatment was delivered
over a 24-hour period using machine-driven and hand
instruments. Test subjects received an adjunctive course of
systemic antibiotics consisting of (500 mg) AMX and (500 mg)
MTZ three times a day for 7 days. It was randomized, double-
blinded, placebo-controlled clinical trial for 6-month duration
on 41 study population. All these included studies showed
statistically signifcant improvement in clinical parameters
when SRP is done along with systemic administration of
antibiotics [Table 2].
Qualitative data synthesis
Because of the limited number of studies, the heterogeneity
of the study design, dosage and duration of MTZ and AMX
administered, and the inability to retrieve the result data
from the published articles, no study data could be pooled for
statistical process to decipher the effcacy (in terms of changes
in outcome measures) of these antibiotics prescribed along with
SRP against aggressive periodontitis in human beings.
DISCUSSION
The present review attempted to systematically evaluate any
available randomized, controlled human study on the effect
of AMX and MTZ in aggressive periodontitis published up
to March 2011. The focus was on fnding suffcient evidence
from existing clinical studies to explore the effectiveness of
antibiotics along with SRP in aggressive periodontitis. Quality
assessment of included studies was based on the checklist
obtained by modifying the popular CAMARADE 10-item
checklist
[7]
designed by Macleod et al., for evaluating the quality
of animal experiments conducted for stroke drugs.
All three included studies are double blinded and of 6-month
duration, and compared SRP with AMX and MTZ: and SRP
with placebo medications. These three included studies
matched each other in duration of the study, but they are
heterogenic in design, dosage of antibiotics administered,
outcome measured, sample size; and compared SRP with or
without antibiotics. The critical question addressed in this
review wasdoes the use of systemic anti-infective drug
therapy in conjunction with SRP add to the benefcial clinical
and microbiological outcome achievable with SRP alone in
generalized aggressive periodontitis? The number of studies
qualifed are three [Table 1], but their heterogenecity did not
allow to subject them to statistical analysis to draw a conclusion,
whether SRP along with antibiotics proves beneficial in
treating generalized aggressive periodontitis compared with
SRP alone or antibiotics as monotherapy. It is noteworthy
that all of the studies qualifed in this systematic review had
small sample size, and severity of the included aggressive
periodontitis, genetic variations, and exclusion of patients with
syndromes is not mentioned. Treatment outcome in aggressive
periodontitis patient may be dependent on patients hereditary
background, their immunity component, and underlying
Table 2: Abstracts included after text screening which fulflled inclusion criteria of randomized placebo-controlled
double-blinded clinical trials of 6-month duration
Reference Patient group Study type level
of evidence
Heller, et al.
[8]
N=31
patients with
generalized
aggressive
periodontitis
6 months
randomize
double-blinded
placebo-controlled
clinical trial
Full-mouth
ultrasonic SRP
chlorhexidine
rinsing, brushing,
and irrigation.
Subjects received
Systemic AMX
(500 mg) + MTZ
(250 mg) or
placebo, T.I.D. for
10 days
Sub-gingival samples were
analyzed for their composition by
checkerboard at baseline, 3 and 6
months post-therapy. Most of the
periodontal pathogens decreased
signifcantly over a time (P<0.05),
whereas nonperiodontal bacteria
tended to increase in both groups.
Sites that showed attachment loss
and increase in PD harbored higher
levels of Dialister pneumosintes,
Campylobacter rectus, Fusobacterium
necrophorum, Prevotellatannerea,
and Peptostreptococcusanaerobius
than sites that improved after both
therapies (P<0.05)
Systemic AMX+MTZ or
placebos adjunctive to
anti-infective mechanical
debridement were
comparable in lowering
periodontal pathogens
up to 6 months after
treatment
Varela, et al.
[9]
N=35 patients
with GAP
6 months
randomized
double-blinded,
placebo-controlled
clinical trial
Patients received
full mouth
disinfection,
followed by staged
SRP, with or
without systemic
antimicrobials AMX
(500mg)+MTZ
(250mg) TID for 10
days
Test group presented greater mean
pocket depth (PD) reduction and
clinical attachment level (CAL) gain
at sites with initially moderate PD
at 6 months(P<0.03).Test group
presented higher % of sites which
improved 2 mm and ended up with
PD 4 mm or lower % of sites which
worsened 2 mm and remained with
PD>4 mm at 3 months (P<0.01). No
differences were noticed between
groups for those parameters at 6
months
AMX + MTZ bring
additional clinical effects to
the repeated mechanical
and antiseptic treatment
of GAP, at very short time
(3 months), which have
a tendency to fade away
over time (6 months)
Guerrero, et al.
[10]
N=41 patients
with GAP
6 months
randomized
double-blinded,
placebo-controlled
clinical trial
Full-mouth SRP
done over a 24-
hour period. Test
subjects received an
adjunctive course of
systemic antibiotics
consisting of
500 mg AMX and
500 (mg) MTZ three
times a day for 7
days
In both the test and the placebo
groups, all clinical parameters
improved at 2 and 6 months. In
deep pockets (> or =7 mm), the test
treatment resulted in an additional
1.4 mm (95% confdence interval
0.8, 2.0 mm) in full-mouth probing
pocket depth (PD) reduction and
1 mm (0.7, 1.3 mm) of life cumulative
attachment loss (LCAL) gain at
6 months. In moderate pockets
(4-6 mm), the adjunctive beneft was
smaller in magnitude: PPD reduction
was 0.4 mm (0.1, 0.7 mm) and LCAL
gain was 0.5 mm (0.2, 0.8 mm). In
addition, the 6-month data showed
LCAL gains> or =2 mm at 25% of
sites in test patients compared with
16% in placebo (P=0.028). Similarly,
PPD reductions of 2 mm or more
were observed in 30% of sites in test
and 21% of sites in placebo patients.
Seventy-four percent of pockets with
PPD> or =5 mm at baseline were
4 mm or shallower at 6 months in
the test group. This compared with
54% in the placebo group (P=0.008).
Disease progression at 6 months was
observed at 1.5% of test and 3.3% of
sites in test and placebo, respectively
(P=0.072)
These data indicate that
a7-dayadjunctivecourse of
systemic MTZ and AMX
signifcantly improved
the short-term clinical
outcomes of full-mouth
non-surgical periodontal
debridement in subjects
with GAP
n=3 Data extraction from included clinical studies; n=2 Data extracted from included clinical and microbiological studies; n=1 SRP - Scaling and root planing;
AMX Amoxicillin; MTZ Metronidazole; GAP Generalised aggressive periodontitis; PPD Probing pocket depth
systemic diseases; and effectiveness of antibiotics is also
dependant on these factors. In this systematic review, though
statistical analysis was not possible due to heterogenecity of
studies, the administration of antibiotics along with SRP proved
benefcial. It is well-established fact that diseases caused by
microbial bioflm like aggressive periodontitis are extremely
diffcult to treat. Tissue-penetrating bacteria seen in aggressive
periodontitis make it even more difficult. The scientific
rationale of adding systemic antimicrobial agents theoretically
is to reduce the left-out bacteria after SRP. Although SRP proves
benefcial in disrupting subgingival deposits and removes
bacteria, recolonization of bacteria left after SRP is fast and
recurrence of disease in inevitable; hence, adjunctive role of
antibiotics would be benefcial.
CONCLUSION
This systematic review did not assess statistical analysis due to
heterogenecity of the included studies; though use of antibiotics
along with SRP proved benefcial in some patients, question
regarding whether adjunctive role of antibiotics along with
SRP could prove benefcial in treating generalized aggressive
periodontitis and what is an effective dose and duration of
antibiotic administration was not drawn.
Characteristics of the included studies (n=3)
Included studies were divided into (1) only clinical, (2) clinical
and microbiological studies. Table 2 lists the included studies
n=3 which were divided (1) only clinical, (2) clinical and
microbiological studies.
Characteristics of excluded studies (n=9)
Table 1 lists the excluded studies (These studies are excluded
because they are non-randomized controlled trials).
ACKNOWLEDGMENT
This article is dedicated to my teachers Dr. Vandana K. L., Prof. Dr.
Shobha Prakash, Prof. and Head Cods Davangere.
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How to cite this article: Ahuja A, Baiju CS, Ahuja V. Role of
antibiotics in generalized aggressive periodontitis: A review of
clinical trials in humans. J Indian Soc Periodontol 2012;16:317-23.
Source of Support: Nil, Confict of Interest: None declared.

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Journal of Indian Society of Periodontology - Vol 16, Issue 3, Jul-Sep 2012 317

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