Original Article

Evaluation of the role of antibiotics in

preventing postoperative complication
after routine periodontal surgery:
A comparative clinical study
Rosh Radhika Mohan, Dwarakanath Chinni Doraswamy, Ahad M. Hussain,
Gayatri Gundannavar, Shobha Krishna Subbaiah, Deepika Jayaprakash

Department of Abstract:
Periodontics, The Background and Objectives: Aim of this randomly controlled clinical study was to evaluate the role of
Oxford Dental College, antibiotics to prevent postoperative complications after routine periodontal surgery and also to determine whether
Bangalore, Karnataka, their administration improved the surgical outcome. Materials and Methods: Forty‑five systemically healthy
India patients with moderate to severe chronic periodontitis requiring flap surgery were enrolled in the study. They
were randomly allocated to Amoxicillin, Doxycycline, and control groups. Surgical procedures were carried out
with complete asepsis as per the protocol. Postoperative assessment of patient variables like swelling, pain,
temperature, infection, ulceration, necrosis, and trismus was performed at intervals of 24 h, 48 h, 1 week, and
3 months. Changes in clinical parameters such as gingival index, plaque index, probing pocket depth, and clinical
attachment level were also recorded. Results: There was no incidence of postoperative infection in any of the
patients. Patient variables were comparable in all the three groups. Though there was significant improvement
in the periodontal parameters in all the groups, no statistically significant result was observed for any group over
the others. Conclusion: Results of this study showed that when periodontal surgical procedures were performed
following strict asepsis, the incidence of clinical infection was not significant among all the three groups, and
Access this article online also that antibiotic administration did not influence the outcome of surgery. Therefore, prophylactic antibiotics for
patients who are otherwise healthy administered following routine periodontal surgery to prevent postoperative
Website:
infection are unnecessary and have no demonstrable additional benefits.
www.jisponline.com
Key words:
DOI:
10.4103/0972-124X.131327 Antibiotic, asepsis, complications, periodontal surgery
Quick Response Code:

INTRODUCTION measures like strict aseptic protocol, anti‑infective

measures like proper sterilization, disinfection,

P eriodontitis is a multifactorial disease

occurring as a result of complex
interrelationship between infectious agents
and host factors. Environmental, acquired, and
genetic risk factors modify the expression of
disease and may therefore affect the onset or
progression of periodontitis.[1] The hallmarks of
periodontal disease are destruction of connective
tissue and bone loss which, if left untreated, may
eventually lead to tooth loss.
Moderate to severe cases of chronic periodontitis
Address for may warrant periodontal surgical procedures.[2]
correspondence: Of the various factors that affect the outcome
Dr. Rosh Radhika Mohan, of periodontal surgical procedures, the most
797/B, 23rd Cross, 19th main, important aspect is prevention of infection during
HSR Layout, 2nd Sector, and following surgery. Sources of infection during
Bangalore ‑ 560 102, surgery in oral cavity include: instruments, hands
Karnataka, India.
of surgeon and assistant, air of the operatory, and
E‑mail: roshrm@
yahoo.com patient’s perioral skin, nostrils, and saliva.[3]
Submission: 12‑04‑2013 As postoperative infection can have a significant
Accepted: 16‑10‑2013 effect on the surgical outcome, preventive
barrier techniques, and other measures should
be taken. If such measures are taken, there is a
very low rate of postoperative infection following
periodontal surgery,[4] thereby obviating the need
for using antibiotics as a prophylactic measure.
However, in actual clinical practice, it has been
observed that different types of antimicrobials
are routinely prescribed following periodontal
surgery.
Few studies support the concept of rapid healing
and less discomfort when antibiotics are used.[5,6]
On the other hand, many well‑conducted studies
have not supported the routine use of antibiotics
after periodontal surgery and concluded that
antibiotics should be used only when there is
a medical indication or when the infection has
already set in.[2,7‑11]
In India, dentists have been known to prescribe
antibiotics more than any other medical personnel,
which is based totally on empiricism without any
protocol or rationale.[12,13] Indiscriminate use of

Journal of Indian Society of Periodontology - Vol 18, Issue 2, Mar-Apr 2014 205
 Mohan, et al.: Current status on antibiotics after routine periodontal surgery
antibiotics carry the risk of development of gastrointestinal
tract problem, colonization of resistant or fungal strains,
cross‑reaction with other drugs, allergies, and increased cost
of treatment.[14]
Presently, guidelines for the selection and administration
of antibiotics as prophylaxis following surgery are lacking.
Hence, this particular study was undertaken to assess
the incidence of clinical infection and role of antibiotics
in preventing infection in patients undergoing routine
periodontal surgery and its influence on the surgical
outcome.
MATERIALS AND METHODS
In this randomly controlled clinical trial, 45 patients with
moderate to severe chronic periodontitis requiring flap surgery
were recruited from the Department of Periodontics. The study
protocol was approved by the ethical committee.
Inclusion criteria
• Patients aged between 25 and 55  years with moderate to
severe chronic periodontitis
• Systemically healthy patients fit for periodontal surgery
• Patients with good oral hygiene maintenance.
Exclusion criteria
• Patients allergic to Amoxicillin and Doxycycline
• Pregnant patients
• Smokers
• Previous periodontal surgery done in the same area
• Antibiotic therapy taken 3 months prior to surgery.
Forty‑five patients fulfilling the above‑mentioned criteria
were allocated into three groups (Amoxicillin, Doxycycline,
and control groups). Informed consent was obtained from the
patients. Three weeks following phase I therapy, a periodontal
evaluation was performed to confirm the suitability of sites for
periodontal flap surgery.
The following parameters were measured at baseline and
3 months following surgery:
• Plaque index (Silness and Loe)
• Gingival index (Loe and Silness)
• Probing pocket depth (PPD)
• Clinical attachment level (CAL)
• Gingival recession (GR)
• Tooth mobility.
Patients from both test and control groups with persistent
probing depths equal to or more than 5 mm in at least three
teeth in a sextant were subjected to periodontal flap surgery
in a specially prepared surgical room setup. Antibiotics
were started 1 day prior to surgery and continued for 5 days
thereafter, wherein Group A patients were administered
Amoxicillin 500 mg three times a day and Group B patients
were administered Doxycycline 200 mg as a loading dose and
100 mg thereafter. Group C patients were controls without
any antibiotic prescription. Nonsteroidal anti‑inflammatory
drug (Ibuprofen 400 mg + Paracetamol 333 mg) thrice daily for
a minimum of 3 days was prescribed for all the three groups
after surgery.
206 Journal of Indian Society of Periodontology - Vol 18, Issue 2, Mar-Apr 2014
Surgical aseptic protocol and infection control measures
All the periodontal surgical procedures were carried out in a
fumigated enclosed surgical room with restricted entry and
proper drainage and water supply system in place. Anybody
with any source of infection was not allowed to enter the
room. All personnel assigned in the operating room practiced
standard presurgical procedures which included autoclaved
surgical gowns, head caps, masks, and separate in‑house
footwear.
Dental operatory tools, including dental chair, were cleaned
daily with a disinfectant (Bacillol 25). Exposed areas were
covered with aluminum foils. Disposable glasses and
autoclaved disposable suction tips were used along with
distilled water as water source.
High‑volume evacuation suctions were used for decreasing
the aerosol production. Spittoon and tumbler water lines
were flushed for at least 5 min before and after the surgical
procedure. All instruments to be used were precleaned,
segregated, and packed in autoclavable sealed pouches which
had chemical spore testing test strips attached to them and were
then autoclaved [Figure 1].
Operator and assistant performed a presurgical scrub with
a germicidal soap using vigorous friction before the surgical
procedure. Patient preparation was done with povidone
iodine presurgical facial scrub. Pre‑procedural mouthrinse
with 10 ml of 0.2% chlorhexidine was done. Proper barrier
methods were used.
Surgical procedure
Surgical procedure was performed under local anesthesia
with 2% lignocaine containing adrenaline (1:200,000). Buccal
and lingual (palatal) surgical incisions were made and
mucoperiosteal flaps were elevated [Figures 2 and 3].
Complete debridement of the surgical site and scaling and
root planing were done with ultrasonic device and hand
curettes [Figure 4]. Flaps were approximated with 3‑0 silk
sutures [Figure 5]. Periodontal dressing was placed and
postoperative instructions were given [Figure 6]. Application
of cold pack was not advised for patients belonging to any of
the three groups post‑surgically.
Postoperative care and evaluation
Test and control group patients were instructed to continue
the medication and were asked to abstain from brushing on
the surgical site for at least 2 weeks. Use of chlorhexidine
gluconate (0.2%) was advised for 1 min twice daily immediately
1 day after the surgery for 1 month. Patients were asked
to record the incidence of pain, swelling, and increase in
temperature, or any other associated adverse effect after
surgery which was graded as mild, moderate, or severe in
nature. These were recorded in a tabular chart at two intervals
in a day for up to 48 h after surgery.
Periodontal dressing and sutures were removed 1 week
postoperatively and the operated area was evaluated for
healing, infection, and any signs of ulceration and necrosis
which were tabulated separately in the chart provided
[Figure 7].
 Mohan, et al.: Current status on antibiotics after routine periodontal surgery
Figure 1: Armamentarium
Figure 3: Incision placed
Figure 5: Sutures placed
Figure 7: 1 Week postoperative photograph
In order to avoid bias, all the post‑surgical measurements
were done by previously calibrated periodontists, who were
blinded to the group to which the patient belonged. After the
third month, all post‑surgical parameters were recorded and
evaluated.
Statistical analysis
Analysis of variance (ANOVA) was used to find the
significance of the study parameters between three or more
groups of patients. Chi‑square/Fisher’s exact test was used to
find the significance of study parameters on categorical scale
between two or more groups.
Journal of Indian Society of Periodontology - Vol 18, Issue 2, Mar-Apr 2014 207
Figure 2: Preoperative probing depth (Group B)
Figure 4: Flap reflection and debridement
Figure 6: Periodontal dressing placed
Statistical software, namely, SAS 9.2, SPSS 15.0, Stata 10.1,
MedCalc 9.0.1, Systat 12.0, and R environment ver. 2.11.1 were
used for the analysis of the data, and Microsoft Word and Excel
were used to generate graphs, tables, etc.
RESULTS
All the patients returned regularly for the maintenance
program, without any dropouts. None of the patients belonging
to Groups A and B developed any allergy or unfavorable
response to the drug, requiring discontinuation.
Age and gender of patients
The age of the patients ranged between 21 and 60 years, with
a mean age of 38.27 years in Group A, 37.27 years in Group B,
and 39.93 years in Group C, thereby demonstrating the age
match between the Groups. A total of 16 male patients and
29 female patients participated in the study [Graphs 1 and 2].
Periodontal variables
Plaque index
The plaque scores in all the groups were consistently
maintained between 0.12 and 0.17 throughout the study. There
was no statistically significant difference in the plaque scores
between the groups [Graph 3].
 Mohan, et al.: Current status on antibiotics after routine periodontal surgery
Figure 8: Preoperative photograph (Group A)
Figure 10: Preoperative photograph (Group B)
Figure 12: Preoperative photograph (Group C)
Gingival index
The mean gingival index in all the groups ranged from 0.05
to 0.26 at the end of the study period. Also, no statistically
significant intergroup difference was observed [Graph 4].
Probing pocket depth
The mean PPD in the Amoxicillin group was 3.92 ± 0.58 mm
preoperatively, which reduced to 2.48 ± 0.25 mm postoperatively
[Graph 5, Figures 8 and 9], whereas in Doxycycline group, the
probing depth reduced from 4.04 ± 0.47 mm preoperatively to
2.45 ± 0.28 mm postoperatively [Graph 5, Figures 10 and 11].
In the control group, the probing depth was 4.11 ± 0.51 mm
preoperatively, which reduced to 2.34 ± 0.69 mm postoperatively
[Graph 5, Figures 12 and 13]. The reduction in probing depth
in all the three groups was statistically highly significant.
208 Journal of Indian Society of Periodontology - Vol 18, Issue 2, Mar-Apr 2014
Figure 9: 3 months postoperative photograph (Group A)
Figure 11: 3 months postoperative photograph (Group B)
Figure 13: 3 Months postoperative photograph (Group C)
However, no statistically significant difference in the probing
depth reduction could be seen when the results were compared
among the three groups.
Clinical attachment level
The mean CAL in group A was 0.96 ± 0.18 mm preoperatively,
which reduced to 0.51 ± 0.46 mm postoperatively [Graph 6],
whereas in Group B, these readings were 1.01 ± 0.19 mm
preoperatively and 0.60 ± 0.44 mm postoperatively [Graph 6].
In the control group, the mean CAL reduced from 0.99 ± 0.20 mm
preoperatively to 0.84 ± 0.15 mm postoperatively [Graph 6]. All
these reductions within the groups were statistically significant,
but no difference was seen when the results were compared
among the three groups.
 Mohan, et al.: Current status on antibiotics after routine periodontal surgery

Graph 1: Comparison of age distribution between the patients Graph 2: Comparison of gender distribution between the patients

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Graph 5: Mean probing depths between the three groups Graph 6: Mean clinical attachment level between the three groups

Patient variables Other findings

Temperature Patients were directed to report any other events such as
There was no statistically significant difference among the lassitude, body ache, gastric upset, diarrhea, and headache
different groups [Graph 7]. following surgery.

Pain Overall, there was no statistical significance between the groups

There was no statistically significant difference in the
pain perception among the three groups, 24 h following
surgery. Post‑surgical evaluation done after 60 h showed
that two patients in Group A and two in Group C had mild
pain [Graph 8].
Postoperative swelling
No statistically significant association was observed among the
groups at any of the time intervals [Graph 9].
Other parameters
None of the patients in any group showed signs of postoperative
infection, and overall healing was satisfactory [Graph 10].
in any of the parameters listed above.
DISCUSSION
Oral cavity, which harbors billions of microorganisms as their
natural habitat, is also influenced by a multitude of external
factors, leading to its susceptibility for infection. Though in
actual practice, only a minority of surgical procedures performed
in the oral cavity result in any significant post‑surgical infection,
they could result in needless complications, discomfort to the
patient, delay in healing, and can influence the final outcome
as well. Hence, majority of the surgeons throughout the world
believe in the dictum “to err on the side of safety” and routinely

Journal of Indian Society of Periodontology - Vol 18, Issue 2, Mar-Apr 2014 209
 Mohan, et al.: Current status on antibiotics after routine periodontal surgery

Graph 7: Comparison of incidence of temperature between the three groups

Graph 8: Comparison of incidence of pain between the three groups

Graph 9: Comparison of incidence of swelling between the three groups

prescribe antimicrobials as prophylaxis to prevent post‑surgical
infections. Periodontists are no exception to this.
However, there are neither guidelines nor incontrovertible
evidence to support this practice; also, there is no uniform
system prevailing in different parts of the world to guide
periodontists regarding the type of drug, its dosage, duration,
etc. Literature support for routine antibiotic prescription is
lacking and few studies carried out to address this matter have
provided different conclusions. Hence, as of now, prescribing

210 Journal of Indian Society of Periodontology - Vol 18, Issue 2, Mar-Apr 2014
 Mohan, et al.: Current status on antibiotics after routine periodontal surgery
Graph 10: Comparison of incidence of other parameters between the three group
antimicrobial therapy as prophylaxis to prevent infection
during routine periodontal surgery can only be called as
empirical and is not based on solid evidence.
This study, therefore, envisaged to evaluate the effects of
antimicrobial prophylaxis on all the parameters of healing
following periodontal surgery as compared to no drug
therapy, besides attempting to find out the actual incidence
of post‑surgical infections. The patients recruited were all
systemically healthy, belonged to a comparable age range, and
were compliant. Oral hygiene maintenance was periodically
reinforced and assessed by clinical parameters from baseline
to 1 month prior to the surgery. Patients who did not maintain
adequate oral hygiene and who were noncompliant were
not included in the study as literature reviews have shown
that noncompliant subjects had the highest risk of recurrent
periodontitis, even if they had completed the treatment plan.
The surgical technique and the type of periodontal defects
were also standardized.
Results of the study clearly showed that properly performed
periodontal surgery does not result in post‑surgical infection
or any complications. This was amply substantiated by lack
of any undesirable outcome such as persistent excessive pain,
severe swelling, abscess formation, ulceration, and necrosis in
any of the patients. None of the patients had any noticeable
systemic effect following surgery. These results correspond
with the reported results of the studies done earlier,[2,7‑10] but
literature review has supported the potential beneficial effects of
prophylactic antibiotics in patients with systemic involvement.
Amoxicillin and Doxycycline were chosen for the two
experimental groups, mainly because most of the dental
practitioners prefer Amoxicillin whereas majority of the
periodontists prefer Doxycycline for its effect against
periodontal pathogens due to convenience of its usage, which
thereby improves patient compliance. Metronidazole was not
considered, as patient compliance has been found to be poor
due to its side effects.[15]
Different patient variables (ulceration or necrosis, signs of
delayed healing, adverse systemic effects such as fever, malaise,
lassitude, etc.) indicated that there was no difference between
any of the groups. These findings are in agreement with those
of earlier studies.[2,13,16] The role of antimicrobials in improving
periodontal variables following surgery is controversial.[17,18]
Journal of Indian Society of Periodontology - Vol 18, Issue 2, Mar-Apr 2014 211
Studies in which randomized controlled trials (RCTs) were
conducted reported that selective antimicrobial agents when
used as adjunctive to periodontal surgical procedures improved
the periodontal parameters,[19‑21] whereas meta‑analysis studies
reported that adjunctively used systemic antimicrobials did
not show statistically significant results.[18,22‑24] However, in this
study, there was no difference in the periodontal parameters
such as plaque index, gingival inflammation, pocket depth
reduction, or CAL among the different groups.
Hence, this study has clearly demonstrated that routine
periodontal surgery when properly performed does not result
in post‑surgical infection and produces beneficial outcome
regardless of whether prophylactic antimicrobials have been
prescribed or not.
In this era where antimicrobials are being prescribed without
any basis, it often leads to abuse and misuse of them. The
development of various resistant strains of microorganisms
has frequently resulted in serious unmanageable infections.[25]
Hence, the outcome of this study is very significant, particularly
in a country like India where there is no antibiotic policy
prescribed by the regulatory bodies.
But it should be understood that this study was carried out
in a hospital setting with a strong surgical protocol. Whether
the same result can be obtained in an ordinary clinical setting,
especially in a dental clinic setup, is questionable. Further
studies are required to be done in less than ideal settings before
it can be unequivocally recommended to discontinue the use
of prophylactic antimicrobial drug following periodontal
surgical procedure.
CONCLUSION
The results of this study revealed that periodontal surgery done
under strict surgical protocol did not result in postoperative
infection, irrespective of whether antibiotics were prescribed
or not. Hence, it is concluded that prophylactic medication
of patients with antibiotics who are otherwise healthy
following routinely properly performed periodontal surgery
is unnecessary and has no demonstrable additional benefits.
Further studies need to be conducted in different clinical
settings before recommending changes in the antibiotic policy
for surgical procedures.
 Mohan, et al.: Current status on antibiotics after routine periodontal surgery
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How to cite this article: Mohan RR, Doraswamy DC, Hussain AM,
Gundannavar G, Subbaiah SK, Jayaprakash D. Evaluation of the
role of antibiotics in preventing postoperative complication after
routine periodontal surgery: A comparative clinical study. J Indian
Soc Periodontol 2014;18:205-12.
Source of Support: Nil, Conflict of Interest: None declared.
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