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DEPARTMENT OF PERIODONTCS

ANTIBIOTICS IN

PERIODONTCS

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ANTIBIOTIC

• Antibiotics , which are chemical substance originally produced by microorgnism,either retard the growth of microorganism

or result in their death

• Now some antibiotics are chemically synthesized or semi synthesized

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An Ideal Antibiotcs Should be

1. Selective and effective against micro organism

2. Bactericidal more than bacteriostatics

3 Not ineffective as a result of bacterical resistance 4. Not be inactivated by enzyme, plasma, protein or by body fluid 5. Maintained for sufficient period in blood plasma 6. Have minimal adverse effect

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Classification of Antibiotic• Based on chemical structure

1 sulfonamides- sulfadiazine, PAS

2 Quinolones - ciprofloxacin , Nalidixic acid

3 Tetracyclines – Doxycycline, Tetracycline

4 Aminoglycosides – Gentamycin,

streptomycin

5 Macrolides – Erythromycin, Roxithromycin,

Azithromycin

6 B lactam antibiotic- Penicillins

Cephalosporacin

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7 Nitroimidazoles - Metronidazole,

Tinidazole

8 Imidazoles derivatives- ketoconazole,

9 Polypeptides Antibiotic – Bacitracin

Polymyxin -B

10 Nicotinic acid derivatives

Isoniazid, Pyrazinamide

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Common Antibiotic used in Common Antibiotic used in PERIODONTCSPERIODONTCS TetracyclineTetracycline Metronidazole Metronidazole Amoxicillin Amoxicillin Clindamycin Clindamycin CephalosporinCephalosporin Ciprofloxin Ciprofloxin

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Antibiotic Resistance• Microorganism are some time resistance or

unaffected by an antibiotic• Resistance can be

Natural, that present before contact with drug

Acquired, that developed during exposure with drug

• The development of acquired resistance

is genetic, with change in DNA , and is inherited by subsequent generation

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* Micro organism are resistance to particular drug frequently are resistance to other chemically related antimicrobial agent

This is referred as Cross Resistance* In antibiotic resistance implies In activation of antibiotic by bacterial

enzyme Development of alternate pathway of drug metabolism by bacteria Biochemical alternation in the bacteria

that prevent the uptake or binding of the

antibiotic

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TETRACYCLINE

• Widely used in treatment of periodontics

• Broad spectrum antibiotics

• Effective aganist remove > gram- ve

• MOA - inhibiting protein synthesis in

bacteria

• Bacteriostatics, effective against rapidly

multiplying bacteria

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TetracyclineTetracycline Effective in treating periodontal disease because

1. Their concentration in GCF is 2 to 10 times

more than blood serum

2. Ability to concentrate in POCKET

3. Inhibit the growth of

Actinobacillus actinomycetemcomitans

4. Have anti collagenase effect inhibiting tissue

destruction

5. Increase bone regeneration

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Classification of Tetracycline based on generation

Group 1 Chlortetracycline

oxy tetracycline

Tetracycline

Group 2 Demeclocycline

Methacycline

Lymecycline

Group 3 Doxycycline

Minocycline

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Tetracyclines..........Tetracyclines..........

INDICATION

Dental condition

1. Localized aggressive periodontitis

because effective against

A. actinomycetemcomitans

2. other Aggressive periodontitis.

3. Refractory periodontitis.

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Tetracyclines..........Tetracyclines..........

• Other condition Mixed bacterial infection - in respiratory infection - in genital urinary infection - G I T infectionContra indication Pregnancy Feeding mother Liver disorder Kidney disorder

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Tetracyclines.........Tetracyclines.........

Adverse Effect• Permanent discoloration of teeth in offspring due to

administration of drug during last half of pregnancy Administration of drug in 1-st 6 years of life• Teratogenicty• Photosensitivity• GIT disorder Nausea, Vomiting, Diarrhea Epigastric distress Drecress absortion of vitamin k

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Tetracyclines.......Tetracyclines.......

• Lethal hepatic toxicity if tetracycline use in renal disorder• Fancony type syndrome if outdated

tetracycline Use in in renal disorder

Now tetracycline less use in dental & medical, replace by more effective

other combination antibiotic

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Tetracycline StainingTetracycline Staining

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METRONIDAZOLE1. It is effective against anaerobic bacteria & anaerobic parasite 2. Anaerobic bacteria both gram +ve & gram –ve 3. MOA – inhibiting the growth of bacteria by inhibit the bacterial DNA synthesis 4. On set of action – 8 hours 5. Duration of action - 24-48 hours

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METRONIDAZOLE .......

• More effective against obligate anaerobic

gram – ve bacteria

• DOSE

Orally - 200- 400 mg tid

For 7-10 day

Available as

Metrogyl 400 mg

Flagyl 400 mg

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METRONIDAZOLE ........

INDICATION 1. Gingivitis

2. ANUG

3. Chronic Periodontitis

4. Aggressive Periodontitis

5. In Refractory Periodontitis

In combination with amoxicillin

6. After extraction

7. All mixed infection with anaerobic bacteria

8. In severe odontogenic infection

with other antibiotic

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METRONIDAZOLE ..........

Contra indication

1. Patient having alcohol habit

2. Patient taking anticoagulant therapy

B/C it prolonge the pro thrombin

time

3. CNS disorder

4. Blood disorder

5. Cirrhosis of liver

6. Renal disorder

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METRONIDAZOLE ..........

Adverse Effect 1. Abdominal problem

Severe cramp, Nausea, Vomiting,

Diarrhea

2. Metallic taste in mouth

3. Headache disorder

4. Dry mouth

Not use as mono therapy for treatment of

periodontal disease

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Penicillins

• These are B lactam antibiotic

Types

Penicillin –G (Benzyl Penicillin )

acid labile destroyed by gastric acid

Penicillin- V acid stable ( given orally ) Penicillinase resistance penicillin

Methicillin , cloxicillin, Oxacillin Extended spectrum Penicillin amphicilin, amoxicillin, bacampicillin

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AMOXICILLINAMOXICILLIN

• Amoxicillin is a semi synthetic antibiotic

• Known as Broad spectrum penicillin • Effective against gram- ve bacteria • MOA of action – Inhibit synthesis of bacterial cell wall • Onset of action - 1-2 hours• Duration of action - 8 hours

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Amoxicillin .......

• It show excellent absorption after orally

administration

• It susceptible to penicillanase

• (Beta lactamase) produced by bacteria

• For Periodontal therapy

Given combined with clavulanate

Amoxicillin + Clavulanate =

AUGMENTIN

It is against the penicillanase

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Amoxicillin .......

INDICATION

1 As prophylaxis therapy before any periodontal surgery2 Amoxicillin + Metronidazole In localized juvenile periodontitis3 Amoxicillin +clavulanate In refractory periodontitis4 In all other aerobic infection

Contra Indication Hypersensitivity to penicillin

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Amoxicillin .......

DOSE 250 – 500 tid

route of administration

Orally, IM, IV

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Amoxicillin ....... ADVERSE EFFECT

• Amoxicillin is a safe drug un till it is hypersensitive to patient • Toxicity to amoxicillin is rare• Diarrhea • Super infection • Nausea , Epigastric distress• Bleeding disdorder • Urticaria • Allergic reaction • Bacterial resistance

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CLINDAMYCIN • It is macrolide

• MOA – Inhibit protein synthesis in bacterial

cell wall

• As a nature - Bacterio static but in high

dose Bactericidal

• It has ability to penetration in deeper tissue

like bone and deep tissue ,

so has importance in treating periodontal

disease

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Clindamycin ........

• After oral administration

Level in bone similar to level in blood

Level in GCF is more than MIC required

• Effective against anaerobic bacteria

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Clindamycin ........

INDICATION • Treatment of refractory peridontitis

alone or in combination with amoxicillin

Dose – 150 mg tid for 7-10 day

• ANUG

• In deep odontogenic infection

• Osteomyelitis

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Clindamycin ........

Contra Indication Hypersensitivity

Liver disorder

Renal failure

Blood disorder

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Clindamycin .......

ADVERSE EFFECT

1. Main side effcet is

Diarrhea ,gastric upset if taken in

empty stomach

2. Ulcerative colitis

3. Anorexia, metallic taste

4. Allergic reaction

5. Aplastic anemia

6. Insomnia

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CIPROFLOXACIN• It is first generation fluoroquinolone • Effective against gram – ve bacteria including all facultative bacteria &some

anaerobic putative periodontal bacteria • Dose- 500 mg bid Dose should be change according to

severity of disease• MOA Inhibit bacterial DNA synthesis• Onset of action -1 hours• Duration of action – 8 to 12 hours

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Ciprofloxacin ......

INDICATION

1. In Refractory Periodontitis 2. In combination with Metronidazole effective

against A. actinomycetemcomitans Non Dental Condition Typhoid Gonorrhea Skin & Soft tissue infection Urinary tract infection

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Ciprofloxacin ......

• Contra Indication Hypersensitivity Special Precaution Renal disorder Epilepsy Children

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Ciprofloxacin .....

ADVERSE EFFECT

• Nausea vomiting Headache

• Abdominal discomfort

• Inhibiting metabolism of theophyllline, warfarin

&anticoagulant

• Photosensitivity , Hyper pigmentation,

• Hypersensitivity

• Insomnia

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Locally Delivered of Antibiotic

• Limitation of systemic therapy, mouth rinse & irrigation have, promoted for research for development of alternative delivery system • Requirement of treating periodontal disease

include 1. Controlled release of drug 2. Maintained localized concentration of drug at infection site for optimum time 3. Minimal side effect

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Various Locally Delivered of Antibiotic

• ACTISITE (TetracyclinesTetracyclines)

• ARESTIN (Minocycline)

• ATRIDIOX (MetronidazoleMetronidazole )

• PERIO CHIP (Chlor hexidine)

• Elyzol (MetronidazoleMetronidazole )

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Powered irrigation device

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Tetracycline – Containing Fiber (ACTISITE ))

First local delivery product for antibiotic Feature 1. Ethylene or vinyl acetate copolymer fiber 2. Diameter 0.5 mm 3. Containing Tetracycline 12.7 mg/ 9 inch 4. When packed into periodontal pocket, it is well tolerated by oral tissue 5. For 10 day it sustains tetracycline concentration exceeding 1300 ug/ ml

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ACTISITE

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Actisite.......

Effect Reduction in probing depth

Reduction in Bleeding on probing

Increase in clinical attachment level

Normally no staining on teeth Reduction in plaque micro organism

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Sub Gingival Delivery Of Doxycline ATRIDIOX

• Atridox is gel system that incorporate the antibiotic Doxycycline (10%) in syringe able gel system • It is a Biodegradable mixture• Drug introduced Subgingivally• Applied with or without Scaling or Root planning

Effect Increase in clinical attachment level Reduction in plaque micro organism Probing depth reduction

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ATRIDIOX

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Sub Gingival Delivery For Minocycline (ARESTIN)

1. Sub Gingival Delivery system contain 2% (w/w) Minocycline hydrochloride2. Use as a adjuvant to Sub Gingival debridement3. Biodegradable mixture in syringe Effect are Reduction in Pocket depth Reduction in gingival bleeding Reduction in plaque microorganism

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Sub Gingival Delivery Of METRONIDAZOLE

ELYZOL• ELYZOL Containing an oil based Metronidazole 25% dental gel

• Applied in viscous consistency to the pocket where is liquidized by body heat

and hard again contact with water • Preparation contain Metronidazole benzoate, which is converted into active substance by esterase in GCF

• Effective after scaling &Root planning

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Local Delivery Of Antiseptic Agent • Chlorhexidine delivery system (Perio chip)

It is a resorbable delivery system periochip ,tested for Chlorhexidine gluconate

• It is small chip 4 x 5 x .35 mm

• Composed of

Bio degradable hydrolyzed gelatin matrix

Cross linked with glutraldehyde

Glycerin with water

2.5 mg Chlorhexidine gluconate

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PERIO CHIP

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• It is rounded on one end so easily inserted • Perio chip released Chlor hexidine and maintain drug concentration in GCF more than 1000 ug/ml for atr least 7 day • Bio degradable in 7 to 10 day

Advantage

Reduction in probing depth Reduction in Bleeding on probing Increase in clinical attachment level Normally no staining on teeth A

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REFERENCES

Jan Lindhe – Clinic Periodontology & Implant Dentistry, Fourth Edition.

Carranza’s Clinic Periodontology, Ninth Edition.

J D Manson & B M Eley – Outline of Periodontics, Fourth Edition.

Guru Raja Rao – Text Book Of Periodontology, Second Edition.

Periodontal Medicine, Rose, Genco, Cohen Menley

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