Original Article

Antibiotics in periodontal surgeries:

A prospective randomised cross over
clinical trial
Sheetal Oswal, Shivamurthy Ravindra, Aditya Sinha, Shaurya Manjunath

Department of Abstract:
Periodontics and Aims and Objectives: (1) To evaluate the need of antibiotics in periodontal surgeries in reducing postsurgical
Implantology, infections and explore if antibiotics have any key role in reducing or eliminating inflammatory complications.
Sri Hasanamba Dental (2) To establish the incidence of postoperative infections in relation to type of surgery and determine those
College and Hospital, factors, which may affect infection rates. Materials and Methods: A prospective randomized double‑blind
Vidyanagar, Hassan, cross over clinical study was carried out for a period of 1‑year with predefined inclusion and exclusion criteria.
All the patients included in the study for any periodontal surgery were randomly divided into three categories:
Karnataka, India
Group A (prophylactic), Group B (therapeutic), and Group C (no antibiotics). Patients were followed up for 1‑week
after surgery on the day of suture removal and were evaluated for pain, swelling, fever, infection, delayed wound
healing and any other significant findings. Appropriate statistical analysis was carried out to evaluate the objectives
and P < 0.05 was considered as statistically significant. Results: No infection was reported in any of 90 sites.
Patients reported less pain and postoperative discomfort when prophylactic antibiotics were given. However,
there were no statistical significant differences between the three groups. Summary and Conclusion: There
was no postoperative infection reported in all the 90 sites operated in this study. The prevalence of postoperative
infections following periodontal surgery is  <1% and this low risk does not justify the routine use of systemic
antimicrobials just to prevent infections. Use of prophylactic antibiotics may have role in prevention of inflammatory
Access this article online complication, but again not infection.
Website: Key words:
www.jisponline.com Antibiotics, periodontal surgery, postoperative infection
DOI:
10.4103/0972-124X.142443
Quick Response Code: INTRODUCTION are continuously raised about the overuse
and side‑effects, including the emergence of

P eriodontal surgical procedures by their

nature carry with them an attendant risk
of developing complications, one among
antibiotic‑resistant bacterial strains.

Although reports have advocated postoperative

which includes infection. Various antiinfective
measures have been advocated to improve
clinical outcomes following postsurgical
intervention. [1,2] These measures include:
(1) Meticulous professional mechanical
debridement, (2) application of antiseptics in
dressings and/or rinses, and (3) administration
of systemic antibiotics. The value of optimal
plaque control (mechanical debridement) as a
prerequisite for successful treatment outcomes is
Address for
well‑documented.[1,2] Furthermore, studies have
correspondence:
Dr. Sheetal K. Oswal, established the key role of chlorhexidine (CHX)
Department of Periodontics digluconate rinses in favorable healing responses
and Implantology, following surgery.[3] In contrast, the routine use
Sri Hasanamba of perioperative/postoperative antibiotics in
Dental College and anticipation and prevention of postoperative
Hospital, Vidyanagar, infection appears for the most part to be based
P.O. Box 80, Hassan - on empiricism and unsubstantiated. Furthermore
573 201, Karnataka, India.
with increase in use of bone grafts, guided tissue
E-mail: drsheetaljain09@
gmail.com regeneration (GTR) membranes and implants,
the use of antibiotics have further increased.
Submission: 01-06-2013 This is all the more significant in our current
Accepted: 17-12-2013 era of periodontal practice where concerns
antibiotics to reduce pain, swelling, and to
improve wound healing and treatment outcomes
following gingivectomy,[4] osseous resective,[5,6]
regenerative,[7,8] and implant[9,10] surgery, only
a relatively few studies have attempted to
determine the actual prevalence of postoperative
infection following periodontal surgery with
and without the use of antibiotics. Antibiotic
prophylaxis has not been shown to offer an
advantage in preventing postoperative infections
or affecting the outcome of periodontal surgery;
although there a few reports, which indicate
reduction in postoperative pain and swelling.[6-11]
In addition, infection rates following periodontal
surgery when no antibiotics were used have
been reported to be low, ranging from <1%[6,12]
to 4.4%[11,13,14] [Table 1] for routine periodontal
surgery and 4.5% following implant surgery.[15]
A literature review conducted recently on effects
of antibiotics on implants showed success rate of
92% when no antibiotics were used, 96% when
prophylactic antibiotics were used and 97% when
postoperative antibiotics were used.[16]

570 Journal of Indian Society of Periodontology - Vol 18, Issue 5, Sep-Oct 2014
 Oswal, et al.: Antibiotics in periodontal surgeries

Table 1: Use of antibiotics and incidence of infections in various periodontal surgeries

Primary Study Number of subjects Antibiotic dosage and Periodontal surgeries Infection rate (%)
author design and surgeries regimen
Kidd and RCT Flap operations Group 1: Penicillin 250 mg Curretage and osseous Healing was more advanced
Wade in 17 patients on 4 days×5 days immediately recontouring with less pain, discomfort
opposite sides of the before surgery and swelling in penicillin
same jaw Group 2: Placebo compared to placebo
Appleman CCT 31 Group 1: Cephalexin 500 mg Apically positioned flap ‑
et al. 4 days×3 days 1 h before
surgery
Group 2: Placebo
Pack and Retrospective 927 surgeries in Penicillin 250 mg Different periodontal, Overall 9/927 (1)
Haber 218 patients 4 days×7 days or Ery 250 mg osseous and mucogingival 1/43 (2) with antibiotics
4 days×7 days surgeries 8/884 (<1) without antibiotics
Checchi Retrospective 498 surgeries in OHI+SRP for all patients 360 osseous contouring Overall 21/498 (4.2)
et al. 231 patients Surgery+tetracycline 138 mucogingival surgeries 2/53 (3.80) developed
(250 mg 4 days×7 days) in with no bone involvement infections with antibiotics
53/498 surgeries 19/445 (4.40) developed
CHX was given to all patients infections without antibiotics
for 14-21 days postoperatively
Powell Retrospective 1053 surgeries in Antibiotics administered Flap curettage, Overall 22/1053 (2.09)
et al. 395 patients pre‑ and postsurgery gingivectomy, osseous 8/281 (2.85) developed
Dosage and duration not resective surgeries, bone infections with antibiotics
defined grafts and GTR, free soft 14/772 (1.81) developed
tissue autografts, SECT infections without antibiotics
grafts, coronally positioned 17/900 (1.89) when CHX
flaps, ridge preservation and was used and 5/153 (3.27
augmentation, and implants when CHX was not used
RCT – Randomized controlled trial; CCT – Controlled clinical trial; OHI – Oral hygiene instruction; SRP – Scaling and root planning; GTR – Guided tissue
regeneration; SECT – Sub‑epithelial connective tissue; CHX – Chlorhexidine

Given these observations, and the fact that the vast majority
of patients undergoing periodontal surgical therapy will not
develop infection, we conducted a prospective double‑blinded
randomized cross over clinical trial, first of its kind, with
following aims and objectives:
• To evaluate the need of antibiotics in periodontal surgeries
in reducing posturgical infections
• To establish the incidence of postoperative infections in
relation to type of surgery
• To explore if antibiotics have any key role in reducing or
eliminating inflammatory complications such as pain and
postoperative discomfort
• To determine the actual rates of postsurgical infections and
those factors, which may affect infection rates?.
replacement, rheumatic fever etc.) and with a full mouth plaque
score <20% were excluded.
Following completion of Phase 1 therapy consisting of oral
hygiene instructions and scaling and root planning, 70 patients
were enrolled in the study. Participants were randomly
assigned to any of the following three groups by lottery
method.
Group A (prophylactic)
Prophylactic antibiotic (1 g amoxicillin 1 h before the surgery).
No antibiotics were given postoperatively. Only analgesics
and antiseptic mouth wash were prescribed (n = 31 sites in
23 patients).

MATERIALS AND METHODS Group B (therapeutic)

Experimental design
A prospective randomized cross over clinical trial was carried
out in 70 individuals selected from outpatient Department of Sri
Hasanamba Dental College and Hospital, Hassan for a period
of 1 year from October 2011 to October 2012. The research
protocol was approved by the Ethical Committee and Review
Board of Sri Hasanamba Dental College and Hospital, Hassan.
Verbal and written informed consent was obtained from all the
subjects participating in the study.
Study population
Patients requiring any periodontal surgery with no history of
antibiotics in the 6 months preceding the start of the study were
included. Patients with systemic diseases or conditions (ASA2
and above) that affect healing and those requiring prophylactic
antibiotics when there is a medical condition (heart valve
Therapeutic antibiotics were prescribed. Amoxicillin 500 mg
tid for 5 days after surgery. Analgesics and antiseptic mouth
wash were also prescribed (n = 35 sites in 25 patients).
Group C (control)
No antibiotics given either prophylactically or postoperatively.
Only analgesics and antiseptic mouth wash were
prescribed (n = 34 sites in 22 patients).
Periodontal surgeries were carried out in 100 sites in
70 patients. Surgical procedures performed were open
flap debridement, osseous resective surgeries, distal
wedge procedures, regenerative therapy (bone grafting),
mucogingival surgeries (coronally advanced flap, free gingival
grafting (FGG), free connective tissue grafting,) frenectomy,
and crown lengthening with or without ostectomy. All
the surgical procedures were carried out by postgraduates

Journal of Indian Society of Periodontology - Vol 18, Issue 5, Sep-Oct 2014 571
 Oswal, et al.: Antibiotics in periodontal surgeries

in the department. When a patient was planned for a full Table 2: Patient characteristics
mouth surgery, the same patient was subjected to different Group A Group B Group C
regimens (prophylactic, no antibiotic, or postoperative (n=28 sites) (n=29 sites) (n=33 sites)
antibiotics). Smokers were asked to at least refrain from (%) (%) (%)
smoking until the day of suture removal. Males 16 (57) 14 (48) 18 (55)
Females 12 (43) 15 (52) 15 (45)
Surgical procedure Number of smokers 02 (0.03) 02 (0.1) 03 (0.1)
Local anesthesia was administered to all patients before 01 (former smoker)
Adverse drug effects
surgery. The flaps were sutured and in all cases the wound
Gastritis 1 ‑
was protected with a surgical dressing which was removed Diarrhea 1
after a week. CHX mouthrinses were given to all patients for Patient compliance No dropouts No dropouts No dropouts
14-21 days postoperatively

All the examinations were done 1 week after surgery on the Table 3: Surgical procedure performed in all three groups
day of suture removal. The clinical parameters were recorded Surgical procedure Group A Group B Group C
by an examiner who was masked to the treatment received, (n=28) (n=29) (n=33)
whereas another clinician carried the surgery and provided Flap surgery 13 11 13
the treatment in all the three groups. Patients were evaluated Flap surgery with bone grafting 08 07 9
for pain, both immediate and progressive (measured on visual Surgical crown lengthening 1 2 2
analog scale [VAS]), swelling, fever, delayed wound healing with ostectomy
and any other significant findings. Any adverse effects due to Surgical crown lengthening 1 1 1
the drug administered and patient compliance for the drug was without ostectomy
Frenectomy 1 1 2
also noted [Tables 2 and 3]. Subjects were instructed to report Semi lunar flap 1 ‑ ‑
if any increased or progressive pain and swelling occurred FGG ‑ 2 2
48-72 h postsurgery. Any other unscheduled return in which the Coronally advanced flap 2 2 2
provider placed a patient on antibiotic therapy after surgery was SECT graft ‑ 1 1
also considered as an infection. The subjects were monitored for Implants 1 1 1
1 month after surgery for any delayed complications. Others 1 (socket
preservation)
The data collected were examined to determine if there was any FGG – Free gingival graft; SECT – Sub‑epithelial connective tissue
relationship between the prevalence of postoperative infection
and treatment variables such as number of surgeries per Group B also complained of fever postoperatively. 3 patients in
patient, type of surgery, size of surgical site, operator’s skill and Group B and 1 patient in Group C had delayed wound healing.
experience, use of bone grafts, soft tissue grafts, and smoking. 1 patient each in Group B and C also had apthous stomatitis and
2 patients in Group C had herpes labialis postoperatively. No
RESULTS Infection was reported in any of 90 sites. However, 1 patient each
in Group C and B developed periodontal abscess at nonsurgical
A total of 100 surgeries were carried out in 70 patients during site on the day of suture removal. The abscess was drained
the study. Three patients in Group A and 1 patient in Group C and healing was uneventful the week after. Graft rejection
failed to follow‑up. Six patients in Group B were discontinued was reported in 2 patients (Group B and C category) [Table 4].
from the trial as GTR was placed during the surgery. A total of
90 sites in 60 patients were analyzed (Group A, n = 28, Group B, There was no statistical significant difference in the incidence of
n = 29 and Group C, n = 33). Males (54%) were more affected infection following flap surgery with grafting and that recorded
than females (46%). There were two smokers each in Group A after flap surgery without grafting in all the three groups. Bone
and B and three smokers in Group C who participated in grafts materials used included allografts and xenografts. In the
the study. Surgical procedures carried out were periodontal same patient, there was no statistical significant difference in
flap, bone grafting, crown lengthening, osteoplasty and the incidence of infection whether or not bone graft was placed
mucogingival surgeries. The most common surgical procedures or osseous surgery was performed.
performed were periodontal flap.
DISCUSSION
Parameters like pain (immediately postsurgery and on the day
of suture removal on VAS consisting of 0-10 scale), swelling, Systemic antibiotics are used as an adjunct to periodontal surgery
fever, delayed healing, apthous stomatitis, and postoperative in specific disease profiles (aggressive/refractory/smokers) for
infection were measured all on the day of suture removal. All more aggressive treatment, in anticipation and prevention of
patients reported mild to moderate pain immediately after postsurgical infections, and in periodontal surgery aiming for
surgery and no pain on the day of suture removal. There were regeneration.
no clinical and statistical significant differences between the
three groups. However, 2 patients reported less pain during Routine use of systemic antimicrobials following periodontal
the surgery when prophylactic antibiotics were given [Table 3]. surgery is not justified as the prevalence of postoperative
infections is  <1%.[12] The rationale of using antibiotics with
Three patients in Group B and 1 each in Group A and C regenerative procedures is to increase the predictability of
reported mild swelling for 2 days after surgery. One patient in results by controlling the subgingival microflora in order to

572 Journal of Indian Society of Periodontology - Vol 18, Issue 5, Sep-Oct 2014
 Oswal, et al.: Antibiotics in periodontal surgeries

Table 4: Comparison of different parameters in various for the superior results when compared with other similar
groups studies. Powell et  al.[14] in their study reported that 18 of
Group Group A Group B Group C P value* the 22 infections (82%) occurred following surgery by general
(n=28) (%) (n=29) (%) (n=33) (%) dentists and residents when compared with 4 (22%) performed
Pain (VAS) by board certified periodontal faculty members. Similar to
Immediate Mean: 2.56 Mean: 2.86 Mean: 2.93 0.85 our study, Pack and Haber (1%)[12] and Gynther et al. (4%)[15]
P value@ 0.91 (NS) 0.85 (NS) 0.99 (NS) (NS) too reported low prevalence of postoperative infections when
Suture removal Mean: 0.06 Mean: 0.53 Mean: 0.06 multiple operators performed the surgeries in a large
day institutional setting. This is in contrast to the study by Checchi
P value@ 0.048 (S) 0.047 (S) 1.00 (NS) 0.0250 (S)
et al.[11] who reported slightly higher incidence of complications.
Swelling 1 (3.33) 03 (10) 1 (3.33) ‑
Fever ‑ 01 (3.33) ‑ ‑ The difference is possibly due to different operative conditions,
Delayed wound ‑ 03 (10) 01 (3.33) ‑ with regard to number of surgeons (single vs. multiple) and
healing different health care environment  (dental school vs. private
Rate of infection Nil Nil Nil ‑ office setting). It is clear from the above data that proper tissue
Apthous stomatitis ‑ 01 (3.33) 01 (3.33) NS manipulation and good clinical technique are more important
Herpes labialis ‑ ‑ 02 (6) NS factors in protection of patients from postoperative infections.
Tooth ‑ 1 ‑ NS
hypersensitivity
Other significant 1# 1# ‑ Various studies characterized infection differently,[11,12,15]
findings 1$ 1$ postoperative infection in the current study was defined
1^ as increasing and progressive soft tissue swelling with the
*Comparison among Group A, Group B and Group C using ANOVA one‑way presence of suppuration. Fever and lymphadenopathy were not
classification test, statistically significant if P<0.05; @Pair wise comparison absolute requirements for classification of infection. Despite the
between Group A, Group B, and Group C (A‑B, B‑C, C‑A) using post‑hoc Tukey lack of exact agreement on what constitutes a clinical infection,
test, statistically significant if P<0.05; #Graft necrosis; $Periodontal abscess
at nonsurgical site; ^Implant exposure without infection. VAS – Visual analog the reported prevalence of infections in all of them is similar.
scale; NS – Not significant
Delayed healing was reported in 4 (4.44%) of all patients, three
reduce the risk of postoperative infection. Studies conducted being in antibiotic group (10%). Neither of these patients was
by Demolon et al.,[17,18] Loos et al.,[19] have concluded that use smokers nor was grafting performed in any of these cases. There
of antibiotic may have helped to control initial inflammation, was no relationship between type of procedure performed and
but had no direct effects of clinical significance on bone infection rates in our study, However free gingival autografts
regeneration or soft tissue attachment at 12 months. showed higher postoperative complications. 2 of the total
5 cases reported complete necrosis of the graft. This is similar
This prospective study was carried out with three different to the large retrospective study conducted by Powell et al.[14]
antibiotic regimens (prophylactic therapeutic and no and Pack and Haber[12] who reported higher infection rates
antibiotic) administered pre and postsurgery. Specific disease following epithelialized free soft tissue autografts, guided bone
profiles  (aggressive and refractory) were excluded, whereas regeneration and enamel matrix derivative.
smokers were included. Several surgical procedures reported
in this study include open flap debridement with and Measurement of pain and swelling is extremely difficult and
without bone grafting, FGG, subepithelial connective tissue tends to be subjective. In the present study, Pain was evaluated
grafting, soft tissue augmentation, coronally advanced flap, by VAS. Patient experienced slightly higher pain when bone
and crown lengthening with and without ostectomy. GTR grafts were used and mucogingival surgeries were performed
procedures were excluded in our study as studies evaluating when compared with other surgeries. This is similar to studies
antibiotics in conjunction with GTR membrane showed wide conducted by Curtis et al.,[20] and Matthews and McCulloch[21]
variability in results. Furthermore, there is no consensus on who reported that mucogingival surgeries and osseous
the appropriate antibiotic, dose, duration or the time to begin surgeries were associated with an increase of 3.5 times more
its administration.[17‑19] pain and discomfort than other periodontal surgeries. Longer
duration of surgery and bone exposure resulting in excessive
There was no infection seen in any of the 90 sites operated in postoperative inflammatory response may be the two reasons
all the three groups (0%). Use of bone grafts was not associated that increase postoperative pain and discomfort in these
with the statistically significant change in postoperative surgeries. Furthermore when intergroup comparisons were
infection rate. Smokers too did not show any infection when made, the pain was similar in both Group B and C, but subjects
compared to nonsmokers. The results are favorable or even experienced less pain when prophylactic antibiotics were given.
superior to previously conducted retrospective studies[6,11‑14] All the other inflammatory parameters (swelling and delayed
that have reported infection rates ranging from <1% to 5.4% and healing) were less in Group A (statistically insignificant)
attests the observation that periodontal procedures performed compared to Group B and C, which were similar.
to modern standards by various operators carry a low risk of
developing postoperative infections. All patients were given topical CHX postoperatively. Clinical
and experimental evidence seems to suggest that CHX enhances
This was a prospective study, where the surgical procedures wound healing, reduces complications and improves clinical
were performed by the postgraduates with a standard protocol parameters following periodontal surgery.[22‑24] However, it
and strict asepsis, on systemically healthy patients with no is not possible to determine to what extent and under what
signs of immunosuppression. These are the few reasons conditions CHX may have contributed to reduction in infection.

Journal of Indian Society of Periodontology - Vol 18, Issue 5, Sep-Oct 2014 573
 Oswal, et al.: Antibiotics in periodontal surgeries
Further studies are needed to assess whether CHX may be
given in selected cases as an effective substitute for systemic
prophylactic antibiotics.
SUMMARY AND CONCLUSION
Within the limits of the study, we confirm previous research
demonstrating low rate of infection following periodontal
surgical procedures. There was no infection reported in all the
90 cases operated in our study. The prevalence of postoperative
infections following periodontal surgery is <1% and this low
risk does not justify the use of systemic antimicrobials just to
prevent infections.
Antimicrobials are powerful agents when used in well‑focused
ways. They should be held in reserve for treatment of certain
forms of advanced periodontal diseases (refractory, aggressive),
in systemically compromised individuals with a reduced host
response and in treatment of postsurgical infections. The other
reasons can be when surgery is performed in an infected site,
when the procedure is extensive taking  >2  h or when large
foreign materials are implanted. Various retrospective and
prospective controlled studies have further reported no benefit
seen from the use of antibiotics even in low to moderate risk
dental implant patients.[15,16] Hence, it is important that the
dental profession diligently consider its responsibility to curb
the use of unnecessary antibiotics and keep antibiotic efficacy
high for when they are truly necessary.
Various other factors are more important in protecting the
patient from postoperative infections. They include aseptic
protocol, skill and experience of surgeon, tissue manipulation
and surgical technique, duration of surgery and control of
systemic and local risk factors with increased susceptibility
to infections. Hence, use of antibiotics should be based on
procedural outcomes and should not be generalized or used
blindly just to be extra cautious in preventing infection.
Therefore, we suggest more double‑blind clinical trials to be
conducted to examine the role of antibiotics in prevention of
postsurgical infections.
ACKNOWLEDGEMENT
I thank all my colleagues and postgraduate students for their support.
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How to cite this article: Oswal S, Ravindra S, Sinha A, Manjunath S.
Antibiotics in periodontal surgeries: A prospective randomised cross
over clinical trial. J Indian Soc Periodontol 2014;18:570-4.
Source of Support: Nil, Conflict of Interest: None declared.
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