antibiotic adjuncts to perio treatment
TRANSCRIPT
ANTIBIOTIC ADJUNCTS TO PERIO DONTAL
TREATMENT
1. Bacterial specificity
2. Should not produce resistant strains
3. Does not cause allergy or toxicity
4. Does not cause other side effects
5. Does not eliminate normal oral flora
6. Cost effective
7. Hence the ideal has not been found!
Properties of an Ideal Antibiotic
PERIODONTITIS
IS A COMPLEX DISEASE THAT INVOLVES THE LOSS OF ATTACHMENT AROUND TEETH RESULTING FROM ACTIONS OF MICROORGANISMS AND THE RESPONSE OF THE HOST TO THESE ORGANISMS.
PERIODONTITIS
THE MOST EFFECTIVE TREATMENT CURRENTLY REQUIRES MECHANICAL ROOT PREPARATION IN THE PRESENCE OR ABSENCE OF SURGICAL REVISION OF THE PERIODONTIUM.
PERIODONTITIS TREATMENT CAN BE
TIME CONSUMING, EXPENSIVE AND FRIGHTENING TO PATIENTS.
PERIODONTITIS
THE SEARCH FOR A MAGIC BULLET IS A HIGH PRIORITY
PERIODONTAL PATHOGENS
GRAM-NEGATIVE ANAEROBIC RODS
GRAM-POSITIVE FACULTATIVE AND ANAEROBIC COCCI AND RODS
GRAM-NEGATIVE FACULTATIVE RODS
PERIODONTITIS
A.a.P. gingivalisT. denticola B. forsythusP. intermediaE. nodatumSpirochetes
PERIODONTAL PATHOGENESISDEPEND ON…
TOTAL BACTERIAL LOAD BINDING OF THE DRUG TO TISSUES BIOINACTIVATION OF THE DRUG BY
NONTARGET ORGANISMS BIOFILM PRESENCE AFFORDING THE
PATHOGEN PROTECTION DRUG RESISTANT PATHOGENS IMPAIRED HOST RESISTANCE RECOLONIZATION FROM SUPRAGINGIVAL
SITES AFTER TERMINATION OF ANTIMICROBIAL THERAPY
ANTIBIOTICS
PENICILLIN MACROLIDES TETRACYCLINE CLINDAMYCIN CIPROFLOXACIN METRONIDAZOLE
SPECTRUM
MACROLIDE
CLINDA CEPHA
AMPI/AMOXY
PEN G/PEN V
ORODENTALINFECTIONS
Antibiotic Adjunctive Therapies
Treatment of aggressive periodontal diseases, chronic periodontitis, refractory periodontitis Initial identification of pathogens Appropriate antibiotic selection Debridement should be carried out first
Systemic antibiotics commonly prescribed: tetracyclines, metronidazole amoxicillin, Augmentin, ampicillin ciprofloxacin, clindamycin Periostat (doxycycline)
PENICILLINS
INHIBIT BACTERIAL WALL SYNTHESIS INDICATED IN ACUTE INFECTIONS FROM GRAM-
POSITIVE BACTERIA RESISTANT ORGANISMS AMOXICILLIN MORE EFFECTIVE CAN BE COMBINED WITH CLAVULINIC ACID WHICH
PROTECTS AMOXICILLIN FROM DEGRADATION NOT EFFECTIVE AGAINST Aa
MACROGLIDES
CLINICALLY ADMINISTRATION DECREASED PLAQUE BUT PATIENTS DEVELOPED ABSCESSES DURING THE STUDY WHICH WORSENED THE CLINICAL PARAMETERS
NO SIGNIFICANT OR LASTING EFFECT WAS SEEN
MACROGLIDES
ERYTHROMYCIN CONTAINS A LACTONE RING TO WHICH SUGARS ARE
ATTACHED WHICH BIND TO BACTERIAL RIBOSOMES AND DISRUPT PROTEIN SYNTHESIS
BACTERIOSTATIC LIMITED ACTIVITY AGAINST PERIODONTAL PATHOGENS LIMITED USE IN PERIODONTAL TREATMENT
TETRACYCLINES
MOST COMMONLY PRESCRIBED ANTIMICROBIALS IN PERIODONTICS
INHIBIT PROTEIN SYNTHESIS BY BINDING TO BACTERIAL RIBOSOMAL UNITS
BROAD SPECTRUM INCLUDES TETRACYCLINE, DOXYCYCLINE,AND
MINOCYCLINE MORE EFFECTIVE AGAINST GRAM POSITIVE GOOD ACTIVITY AGAINST SPIROCHETES,
ANAEROBIC AND FACULTATIVE BACTERIA HIGH CONCENTRATIONS IN CREVICULAR FLUID
TETRACYCLINES
CLINICAL USE IN ADULT PERIODONTITIS FOUND TETRACYCLINE TO BE NO DIFFERENT THAN PLACEBO
RELATIVE TO CHANGES IN PROBING DEPTHS, ATTACHMENT LEVELS AND PERCENTAGE OF SPIROCHETES.
HAVE BEEN WIDELY USED IN TREATMENT OF BOTH GENERALIZED AND LOCALIZED JUVENILE PERIODONTITIS
RELATIONSHIPS WERE FOUND BETWEEN THE DECREASE OF Aa IN THE POCKET AND AN INCREASE IN PROBING ATTACHMENT LEVELS.
TETRACYCLINES
CLINICAL USE IN REFRACTORY PERIODONTITIS WAS BENEFICIAL BY SIGNIFICANTLY REDUCING SPIROCHETES, MOTILE RODS,PROBING DEPTHS AND SUPPURATION.
Tetracycline – Side Effects
Intrinsic tooth staining GI upset, abdominal pain Diarrhea, vomiting Fungal overgrowth Resistant bacterial strains Interferes with bactericidal activity of penicillin's
& cephalosporins
DOXYCYCLINE
A SIMILAR EFFICACY AND SPECTRUM OF ACTIVITY AS TETRACYCLINE
ELEVATED IN GINGIVAL CREVICULAR FLUID AT LEVELS COMPARABLE TO TETRACYCLINE
ABSORPTION OF DOXYCYCLINE IS LESS SENSITIVE TO THE PRESENCE OF FOOD
CLINDAMYCIN
EFFECTIVE AGAINST GRAM-POSTITIVE AND MOST ANAEROBIC BACTERIA
INHIBITS BACTERIAL PROTEIN SYNTHESIS BY BINDING TO BACTERIAL RIBOSOMES
USE OF CLINDAMYCIN IN THE TREATMENT OF PERIODONTAL DISEASE HAS BEEN LIMITED BECAUSE OF POTENTIALLY SEVERE SIDE EFFECTS, SUCH AS ABDOMINAL DISCOMFORT, DIARRHEA, AND
PSEUDOMEMBRANOUS COLITIS
CIPROFLOXACIN
A BROAD-SPECTRUM ANTIMICROBIAL THAT INHIBITS BACTERIAL DNA SYNTHESIS THROUGH ITS BINDING TO DNA GYRASE, AN ENZYME RESPONSIBLE FOR THE UNWINDING AND SUPERCOILING OF DNA.
EFFECTIVE AGAINST GRAM-NEGATIVE BACTERIA, STAPHYLOCOCCI, AND PSEUDOMONAS AERUGINOSA.
MAY PROMOTE THE REPOPULATION OF THE PERIODONTIUM WITH BENEFICIAL MICROFLORA BY VIRTUE OF ITS SELECTIVITY.
CIPROFLOXACIN
IT HAS A MINIMAL EFFECT ON STREPTOCOCCAL MICROBES
CIPROFLOXACIN THERAPY MAY FACILITATE THE REPOPULATION OF THE POCKET WITH MICROFLORA MORE ASSOCIATED WITH PERIODONTAL HEALTH
METRONIDAZOLE
A BROAD- SPECTRUM ANTIMICROBIAL, DISPLAYING ACTIVITY AGAINST ANAEROBIC COCCI, GRAM-NEATIVE BACILLI, AND GRAM-POSITIVE BACILLI
PERMEABLE THROUGH THE BACTERIAL CELL WALL, THE DRUG BINDS DNA AND DISRUPTS THE HELICAL STRUCTURE. BREAKAGE OF THE DNA STRANDS FOLLOWS LEADING TO CELL DEATH.
LEVELS OF THE DRUG IN CREVICULAR FLUID CAN APPROACH TWICE THAT IN THE SERUM.
METRONIDAZOLE
THE EFFECT OF THE METRONIDAZOLE WAS MAINTAINED FOR A TWO TO THREE YEAR RE-CALL PERIOD. IT CAN SIGNIFICANTLY REDUCE THE NEED FOR PERIODONTAL SURGERY COMPARED TO DEBRIDEMENT ALONE.
Mechanism of action: Bactericidal antimicrobial Disrupts DNA synthesis leading to cell death Selectively kills bacterial associated with periodontal
disease Susceptible bacteria include:
Fusobacterium, Bacteroides Peptostreptococcus Treponema, Campylobacter Veillonella
Clinical Considerations: GCF concentrations > blood serum levels When combined with oral hygiene & debridement =
beneficial effect on periodontitis Periodontal surgery may not be necessary
Doxycycline may be substituted for metronidazole If client can’t abstain from alcohol
Before & AfterTreatment with Metronidazole
Probing depth of 6 mm-before
•Tissue shrinkage -after
Before & After Treatment with Metronidazole
6 mm probing depths Surgery has not been required
Some evidence of bone gain – client 2.5 years after initial debridement and use of metronidazole
Dosage: 250 mg tid for 7-10 days 500 mg bid for 1-2 weeks
Doxycycline 100 mg per day or BID
Metronidazole and amoxicillin or Augmentin 250 mg (of each) TID for 7-10 days
AntibioticProphylaxis (Prevention)
1. Bacterial Endocarditis.
2. Prosthetic Joint Infections.
3. Immuno-Compromised Hosts.
4. Procedures and others.
SBE PROPHYLAXIS
RECOMMENDED
Extractions, Periodontal procedures Prophylactic cleaning Implant placement, Re-implantation Endodontic Instrumentation/Surgery
beyond root apex, Placement or removal of orthodontic bands
Intraligamentary LA
SBE PROPHYLAXIS - 1
(1 hr before procedure) STANDARD REGIMEN
Amoxicillin 2 g
PENICILLIN ALLERGY
Clindamycin 600 mg
Cephalexin/Cefadroxil 2 gm
Clarithromycin/Azithromycin 500 mg
SBE PROPHYLAXIS - 2
30 mins before procedure) Failure to take P/O
Ampicillin 2 gm IM/IV Penicillin allergy & Failure to take P/O
Clindamycin 600 mg IV
Cefazolin 1 gm IM/IV
LOCAL DELIVERY OF ANTIBIOTICS
RECURRENT POCKETS IN THE PERIODONTAL MAINTENANCE PATIENT
THE FAILING IMPLANT PERIODONTAL ABSCESSES Work by suppressing destructive
enzymes produced during inflammatory process or suppressing microbes
LOCAL DELIVERY OF ANTIBIOTICS
TETRACYCLINE FIBER (ACTISITE)
DOXYCYCLINE POLYMER (ATRIDOX)
MINOCYCLINE OINTMENT (PERIOCLINE)
ARESTIN (MINOCYCLINE)
Advantages of Controlled Release Agents
Client compliance not an issue
GCF concentration greater than serum levels
Delivery is localized – reduces systemic effects
Reduced side effects
Actisite Periodontal Fiber
Clinical use: Pockets measuring 5 mm, bleed on probing Localized treatment for sites that have not responded to
previous mechanical therapy
How supplied: Cartons of 4 or 10 fibers 23 cm in length 12.7 mg tetracycline hydrochloride Stored at room temperature
Actisite Application:
Treat one quadrant or one side of mouth at a time Client may request anaesthesia Fiber inserted into pocket (circumferential or not)
Takes about 10 minutes/tooth Some control of saliva Should contact pocket base
Actisite
Application: Sealed in place with adhesive
Apply in thin even line along gingival margin Surgical dressing not necessary but has been used
Removed 7-10 days after placement Curette and/or cotton pliers Fiber comes out in mass or pieces Debride areas as necessary
Tissue may appear red following removal
Actisite
Adverse effects: Discomfort Local erythema Little systemic reaction Used with caution in client with history of candidiasis Application around 12+ teeth may result in oral
candidiasis
Actisite
Client instructions: Avoid brushing & flossing Use antimicrobial rinse
Use of CHX may have syngerstic effect Avoid hard or crunch foods, stick foods, chewing gum
Actisite
Clinical Efficacy: Reduction in bleeding on probing and pocket depth
More significant reductions in deeper pockets Reduction in periodontal pathogens Effects of fiber on bone loss, tooth mobility or tooth loss
not established
Arestin
Clinical use: Periodontitis with pockets 5 mm
How supplied: Box containing 2 trays each containing 12 cartridges Cartridge contains 1 mg of minocycline (semisynthetic
tetracycline derivative) microencapsulated in Poly dry powder
Cartridge inserted into a cartridge handle
Arestin
Premeasured, premixed, no refrigeration necessary
Preparing for Arestin
Mechanism of action: Broad spectrum Bacteriostatic GCF levels maintained at high levels for at least 14 days
Application: Insert tip to base of periodontal pocket Expel powder into pocket Bioadhesive microspheres activate & adhere on contact
with moisture Cartridge contains enough Arestin for one periodontal
pocket Clinical trials: 30 sites treated in less than 10 minutes Dressings or adhesives not required
Adverse effects: Headache Pain Mouth ulceration Slu syndrome Stomatitis
Client instructions: Do not eat hard or sticky foods for 1 week Postpone brushing for 12 hours Do not use interproximal cleaning aids for 10 days
Clinical efficacy: 27,000 sites treated, Arestin with debridement demonstrated
27% greater pocket reduction in molars compared to debridement aloneMean reduction of 2 mm (pockets 7
mm +) Effective in furcations
ATRIDOX
A LIQUID BIODEGRADABLE DRUG DELIVERY SYSTEM THAT HARDENS IN THE PERIODONTAL POCKET AND GIVES A CONTROLLED RELEASE OF THE INCORPORATED AGENT
ADMINISTERED VIA SYRINGE STUDIES IN PROGRESS UTILIZING THIS
MATERIAL IN CONJUNCTION WITH ROOT PLANING AND SCALING
NOT FDA APPROVED
PERIOCLINE
MANUFACTURED IN JAPAN APPLIED INTO THE POCKET WITH A
SYRINGE AND BLUNT CANNULA REDUCTION IN PROBING POCKET DEPTH
IN SITES TREATED WITH SCALING AND ROOT PLANING
PERIO CHIP
CHLORHEXIDINE CHIP PLACED IN THE POCKET FOR LONG DRUG DELIVARY
BIBLIOGRAPHY
TEXT BOOK OF PERIODONTOLOGY-CARRANZA
TEXT BOOK OF PERIODONTOLOGY-SHANTHIPRIYA REDDY
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