Periodontitis: Locally delivered antimicrobials as an adjunct to non-surgical treatment


Periodontitis is common leading to destruction of tooth supporting structures and eventually tooth loss.  Subgingival debridement or scaling and root planing (SRP) a key element of treatment although a number of adjunctive therapies have been (antimicrobials, pro- biotics, anti-inflammatory drugs, antioxidant micronutrients) have been investigated. Antimicrobials have been used both systematically (Dental Elf – 23rd Nov 2020) and locally.

The aim of this review was to assess the effects of locally delivered antimicrobials as an adjunct to SRP for the non-surgical treatment of patients with periodontitis.


Searches were conducted in the Medline/PubMed, Embase and Cochrane databases for English language publications only. Randomised controlled trials (RCTs) comparing SRP plus an adjunctive locally delivered anti- microbial against SRP alone of SRP with placebo for treatment of periodontitis with at least 6 months follow up were considered. The primary outcome was change in probing pocket depth (PD) with clinical attachment level (CAL) and pocket closure as secondary outcomes. Study screening and selection was undertaken in duplicate and independently as was data extraction and risk of bias assessment. The Cochrane domains-based tool was used for the risk of bias assessment. Data on clinical outcome variables changes were pooled and analysed using weighted mean differences (WMDs) and 95% confidence intervals (CI). Prediction Intervals (PI) were also calculated.


  • 50 studies reported in 59 papers were included.
  • Studies were from 16 different countries
  • 36 studies used specific site/teeth for evaluation, 17 a full mouth approach with 3 using both approaches.
  • 35 studies used 2 group, 8 had 3 groups and 6 had 4 groups.
  • All the studies were considered to be at high risk of bias except for 3 which were considered to be at moderate risk.
  • Meta-analysis of 6- to 9-month studies showed statistically significant differences for
    • PD, WMD = 364 (95%CI; 0.236 to 0.491), PI (-0.29 to 1.01).
    • CAL, WMD = 263 (95%CI; 0.123 to 0.403), PI (0.43 to 0.96]).
  • Meta-analysis of 12- to 60-month studies a statistically significant difference was only seen for PD, WMD = 190 (95%CI; 0.059 to 0.321).


The authors concluded: –

The use adjunctive locally delivered antimicrobials in periodontitis therapy results in statistically significant benefits in clinical outcomes, without relevant side effects.


The reviewers have undertaken a search of 3 major databases which is likely to have identified the majority of relevant papers. However, as they note, restricting included studies to those published in English may have excluded some relevant papers. While 50 studies were identified almost all of them (47) were considered to be at high risk of bias. The authors also highlighted that the studies results were affected by the study design (split-mouth v parallel) and whether the assessment was partial of full-mouth. In addition, the main results presented are for overall use of sustained release anti-microbials and the specific pharmacokinetic and pharmacodynamic characteristics is very varied.  This means that the findings should be viewed very cautiously.

Another point to be taken into consideration is whether the statistically significant results presented are clinically important. In a previous blog (Dental Elf – 2nd Nov 2020) on use of the chlorhexidine as an adjunct we indicated that an earlier  review suggested that a CAL improvement of , >0.2 – 0.4mm could be considered to be a small benefit. In the Cochrane review of systematic antimicrobials were looked at on Monday (Dental Elf – 23rd Nov 2020) the reviewers were suggesting that 1mm should be a ‘minimally important clinical difference’ for CAL and PD. Wider international discussion and agreement on this would be helpful for future studies.


Primary Paper

Herrera D, Matesanz P, Martín C, Oud V, Feres M, Teughels W. Adjunctive effect of locally delivered antimicrobials in periodontitis therapy: A systematic review and meta-analysis. J Clin Periodontol. 2020 Jul;47 Suppl 22:239-256. doi: 10.1111/jcpe.13230. PMID: 31912531.

Review protocol on PROSPERO

Other references

Dental Elf – 23rd Nov 2020

Periodontitis: Systemic antimicrobials as an adjunct to non-surgical treatment

Dental Elf – 2nd Nov 2020

Chlorhexidine chip as adjunct to scaling and root planing in patients with chronic periodontitis







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