UNIVERSITY OF JORDAN

DENTISTRY 2016

21
Date of Lecture: 00/ 00/ 2019
Done by:
Jenan Doctor:
Abu Oss Nicola
Corrected by:
Bargouth

CONTACT US: ASNAN LAJNEH

All slides are included. Correction of Amal Sheet as the doctor didn’t send a record
Slides are bold.

ANTISEPTICS & ANTIMICROBIALS IN

PERIODONTOLOGY
THERE IS NO SUBSTITUTE FOR A HIGH STANDARD OF MECHANICAL
PLAQUE CONTROL – there is no substitute for tooth brushing. The first line of
defense/prevention against periodontal and gingival diseases is tooth brushing
All antimicrobial agents and mouthwashes are considered adjunctive aids
DON’T prescribe mouthwashes for patients who don’t brush. The patient should first
learn how to brush his teeth, and maintain this habit for a while before you can
prescribe them a mouthwash
Antimicrobials are prescribed in serious medical conditions or for diseases that are not
amenable to treatment

Evaluation of Antimicrobial Agents

Several basic criteria must be discussed when considering a chemical plaque
control agent:
1. SPECIFICITY: they target the causative bacteria only
 Antimicrobial substances, reserved for the treatment of serious
medical infections must, as a rule, not be used to control plaque
locally.
 Systemically administered antibiotics may be used in rare situations
in patients with severe forms of periodontal disease, but only after an
accurate microbiological diagnosis.
 Gingivitis is mainly plaque-induced, and the biofilm contains 300 species
of bacteria. Until this moment, there isn’t one antibiotic that covers such a
wide range of bacteria → it’s useless to prescribe antimicrobial agents for
gingival disease
2. EFFICACY: The antimicrobial agent selected must be effective against
micro-organisms implicated in the etiology of gingivitis and periodontitis.
3. SUBSTANTIVITY/Adsorption: Is a measure of the contact time/time of
adherence that connects a substance and substrate in a given medium.
 Adsorption is the adhesion to the walls of the substance. Absorption is
like when the sponge absorbs water
 Substantivity is the ability to adhere to the surface, not penetrate it
  In treating dental plaque infections, the substantivity of the
antimicrobial agent is of the utmost importance, since the agent needs
a certain amount of contact time in order to inhibit or kill a micro-
organism – it is the most important property in an antimicrobial agent
 That’s why when you use a mouthwash, you should maintain it in contact
with the tooth for at least 30s or 1 min → to give it enough time to adhere
to the tooth’s surface
 Mouthwashes have a transient effect; once you spit them, the effect is
over. If they have a substantive property, then they will adhere to the
surface of the tooth, and their effect will be prolonged up to 24 hours
 Conclusion: antiseptics that are adsorbed are more efficient and sensitive

Aims of Anti-Plaque Agents

1. Should inhibit microbial colonization of the tooth surface and the subsequent
development of plaque
2. Should eliminate plaque already present by dissolution or alteration to form
a less pathogenic plaque.
3. Should inhibit the calcification of plaque to form calculus.
TO DATE, NO SINGLE AGENT SATISFIES TOTALLY THIS CRITERIA.

Limitations of Existing Preparations

1. Many only have a transient effect whilst they are in the mouth.
2. Some are of insufficient concentration to kill bacteria and if their
concentration is increased to do so, they damage the epithelial cells. Also, by
accumulation effect, it will get absorbed by the GI tract and cause a toxic effect.
Conclusion: concentration of 100% will kill the bacteria, but at the same time
destroy the tissues, so we lower the concentration to 2% or 5% (Minimal
inhibitory concentration – MIC)
3. Mouthwashes are only of use on supra-gingival plaque (no effect on
subgingival plaque) and therefore for preventing and controlling gingivitis in
“risk patients” where asepsis is needed e.g. post-surgery, the handicapped,
certain oral mucosal conditions (erosive/ulcerative) and prior to ultrasonic
scaling, chlorhexidine mouthwash is given
All mouthwashes have a transient effect except for chlorhexidine which has a
substantive effect. CXD cannot be prescribed except for the previously mentioned
cases which require asepsis
ENZYME PREPARATIONS:
1. FIRST GENERATION COMPOUNDS
2. SECOND GENERATION COMPOUNDS
First generation compounds:
1. Antibiotics
2. Phenols
3. QUAC’s (quaternary ammonium compounds)
4. Sanguinarine – not used anymore
1ST GENERATION COMPOUNDS REDUCE PLAQUE SCORES BY 20-50%
Second generation compounds:
1. Bisguanides e.g. Chlorhexidine Gluconate
2nd GENERATION COMPOUNDS REDUCE PLAQUE SCORES BY 70%
Third generation compounds – not mentioned in slides at all:
1. Phenolic compound
2. Tertiary ionic compound
3. ..
Some Common Examples
1. PHENOL-BASED PREPARATIONS - Listerine:
 Contains thymol, eucalyptol, methyl salicylate, benzoic acid & boric
acid in a strongly hydro-alcoholic vehicle.
 Shown clinically to reduce plaque scores by 20% and gingivitis scores
by 30%
 Thought to reduce plaque pathogenicity by reducing its endotoxin
activity
 Its popularity decreased compared with 3 years ago due to religious
reasons as it contains high amounts of alcohol (80%). They make non-
alcoholic alternatives nowadays that are as efficient as their predecessors
 One of the most commonly used agents as it is an over-the-counter drug
(doesn’t need a prescription). It is safe and has a transient effect – no
substantivity
 Use 10mL each time
2. QUAC’s:
 Cetyl-Pyridinium Chloride (CTC) appears to be an effective inhibitor
of plaque formation, however not as effective as chlorhexidine. Does
not stain teeth. Causes plaque score reduction by 30%. Marketed under
the brand name Colgate and contains more glycerin that antiseptic.
 3. BISGUANIDES:
 Chlorhexidine Gluconate (CXD/CHD): the most effective anti-plaque
family and the main SECOND GENERATION anti-plaque agents.
Synthesized by ICI. Not an over the counter drug.
 Discovered in 1986 in the UK. Only drug with a substantivity effect that
lasts for 12 hours. Very safe
4. METALLIC SALTS:
 Zinc Salts: good evidence for anti-plaque and calculus properties of
zinc salts of 0.2-4%. Zinc citrate and Triclosan combined in a
toothpaste have been shown to be more effective than either alone.
 Tin Salts: SnF2 based mouth rinses shown to be very effective but
weaker than CXD.
5. SANGUINARINE:
 This is an alkaloid derivative obtained from a plant.
 In its quaternary ammonium form, can inhibit the growth of several
putative periodontopathogens.
 It is retained in dental plaque. Significant anti plaque properties but
low compared to CXD.
6. PLAX:
 Active ingredients for Plax are sodium borate and sodium lauryl
sulfate (makes foam). Teeth feel slick because of the glycerin in the
formula.
7. HEXETIDINE (Oraldene):
 Effective, but less so than chlorhexidine. Does not stain but may cause
hypersensitivity reaction.

Chlorhexidine Data
 Purely topical action doesn’t penetrate oral mucosa.
 Poor systemic absorption and relatively safe – if you swallow 20mL, it’s not
harmful
 Levels of up to 0.2% are tolerated by the eye and safe to skin. If the
concentration increased, blindness and deafness may result. Advise the patient to
use the mouth wash with the head upright, and not tilted backwards. Also tell
them to have their eyes closed when using the mouthwash just in case
THE MOST EFFECTIVE ANTI-PLAQUE AGENT TO DATE.
  Binds to acidic protein groups e.g. phosphates, sulphates, carboxyl ions.
These are present in the salivary glycoprotein's that comprise plaque pellicle,
thus CXD ADSORBS to epithelium and tooth surface
 May also bind to bacterial capsules (polysaccharide in nature) and therefore
reduce bacterial binding to tooth tissue
 Binds to polysaccharides and causes lysis (spilling of cell contents) of bacteria, or
damages the bacterial capsule
 After 1-minute rinse with 0.2% CXD (10mls) 30% of drug is retained. Rinse
for one complete minute to get maximum adsorption. All mouthwashes should be
retained in the mouth for a minimum of 30 seconds
 Ca2+ ions and detergents reduce oral binding and as they are present in
toothpastes, do not use toothpastes immediately before or after CXD use.
You should tell the patient to rinse after brushing by 30 minutes at least, or to
brush after rinsing by 30 mins at least. Why? CXD has a cationic effect while
toothpaste has an anionic effect. When both are used simultaneously, substantivity
of the CXD is lost.
 In the absence of other oral hygiene measures, reduces oral bacterial count
by 85-90%.
 The minimum concentration of CXD required to be effective as a plaque
inhibitor is 0.12% and maximum is 0.2%. More than max will have a toxic effect
and causes damage to the oral mucosa, and less than min will be ineffective as a
plaque inhibitor
 The minimum time for which CXD should be kept in oral cavity during
rinsing, for the effective plaque control, is 30 seconds. The maximum time
needed to achieve its effect is 1 minute.
 It is better to change the brand name of the mouthwash used every 3 months to
change the oral microflora
Unwanted Effects of Chlorhexidine
 Extrinsic staining of the teeth (temporary and removed with polishing) – even if
used for only two weeks (the maximum time of prescription usually), brown lines
will be found inter-proximally, so CXD is contraindicated in patients with bridges
& tooth colored filling materials as it will stain permanently
 Desquamative gingivitis. A type of hypersensitivity to CXD in rare cases
leads to painful erosions of the gingiva and a burning sensation. Temporary
 Altered taste sensation to salty tastes is a short-term complication only.
 Reports of parotid swelling are rare and easily reversible following exclusion
of its use.
Uses of Chlorhexidine
 In the short term following gingival, periodontal or oral surgery
 Long term use in patients whose mechanical plaque control is severely
impaired e.g. fixed orthodontic appliances.
 In handicapped patients as an adjunct to mechanical cleaning (can apply gel
in a soft splint)
 As an aid in the management of drug induced gingival overgrowth.
 Ulcerative gingival conditions e.g. aphthous ulceration.
 HIV positive patients “risk for AIDS” – advise the patient to use to protect against
Kaposi sarcoma
 Periodontal pocket irrigation. Shown to be effective in reducing bacterial
levels within periodontal pockets.
BRAND NAMES:
1. CORSODYL (0.2%)
2. ELUDRIL (0.2%)

Antibiotics in the Management of Periodontal Disease

Indications for use:
 Antibiotics and mouthwashes are useless in patients with chronic periodontitis
as they are not specific or strong enough to target all strains of bacteria “gram
+ve and -ve” in the oral cavity
 In NG, following scaling
 In aggressive periodontitis (not in the new classification, but there is refractory
periodontitis in the new one) → it’s not amenable to our treatment, so we
prescribe an antimicrobial agent since we are aware of the bacteria (subgingival
→ anaerobic) – I copied as it is from Amal sheet
 May be indicated in the management of HIV-P (consult patient’s specialist).
 As an antibiotic prophylaxis.
 In multiple abscess formation with diabetes
 In regenerative technique – bone grafts
Routes of administration:
1. Systemically – traditional method → IV, orally, or IM. Only antibiotics are
given this way
2. Local delivery systems – promising research results and possibly where the
future lies. Antibiotics can also be given topically. Mouthwashes are local
topical antimicrobials
Some doctor, 25 years ago, said that if we administered the drug orally, then resistance
to the drug will develop, so he suggested placing the antibiotic in the pocket
subgingivally directly by injection. As a result, reverse osmosis will not occur, and
bacteria in the pocket will be killed. When the method was tested, 100% of the bacteria
were killed without the bacteria developing resistance
Main drugs used now are metronidazole and doxycycline.
Preferred Drugs
1. The Tetracycline’s:
 Bacteriostatic e.g. Oxytetracycline 250mg QDS. Levels in GCF reach 2-
3 times serum levels. Do NOT use with impaired renal function as the
drug itself can cause liver and kidney failure. Most commonly used drug
for TB. Causes intrinsic discoloration if a pregnant woman takes it.
Bleaching may remove the stains. No longer used in periodontology
 Minocycline or Doxycycline achieves 5-10 X serum levels (it is also a
safe drug with renal compromise – dose 100mg BD. The dose is reduced
to 20mg over 21 days. 100mg or 20mg have the same effect on bacteria).
Safe in nursing mothers. Attaches/gets adsorbed to the cementum and bone
→ gets concentrated 30 to 40 times more than any other systematic AB
 Finally, tetracyclines chelate calcium ions and the ions are essential for
certain metalloproteinases e.g. collagenase to function. Since the
metalloproteinases are involved in the destruction of the periodontal
tissues, these drugs have an additional benefit.
2. Metronidazole (Flagyl):
 One of the most commonly used AB in dentistry & periodontology as it
targets anaerobic bacteria
 Does also appear in GCF 50% higher levels than in serum.
 Weight, age, and patient’s sex are taken into account when prescribing AB
in general
 Effective against anaerobes and dosage is 250mg TDS up to 500mg
TDS (dosage: 250mg, 400mg or 500mg).
 Adults: 500mg 3 times/day
 Children < 18: < 50kg → 150mg; > 50kg → 250 or 500mg
 Advise female patients not to get exposed to the sunlight while
taking the drug as it makes the skin more photosensitive. The
discoloration is irreversible, and its severity depends on how long the
exposure was. The brown patches may be reversible after a long time
  Avoid in pregnancy
 Antimicrobial agents are made from real bacteria. Metronidazole is a
synthetic agent, but we still call it an antimicrobial agent
 The drug of choice for NG. NG is caused by motile spirochetes (bacteria).
This antibiotic is specific to this type of bacteria. The bacteria are also
sensitive to the drug.
3. Amoxicillin: 1st generation antibiotic and was the most common one but has zero
effect nowadays. 2nd generation is Augmentin.
4. Augmentin (250mg amoxicillin and 125mg clavulanic acid) TDS. Clavulanic
Acid is a B-lactamase inhibitor and therefore acts against organisms that are
resistant to penicillin. No allergy/ safe drug. Resistance due to misuse
Modulation of The Host Response in Periodontal Therapy
Until recently, treatment strategies for periodontal disease were primarily based
on the understanding that plaque bacteria and their products mediated the tissue
destruction in periodontal patients.
This concept began to change, however, when investigators reported that host
responses to the causative bacteria were a major contributor to disease
pathogenesis.
With a new understanding of host response and periodontal disease pathogenesis,
it became apparent that inhibition of certain host response pathways might be an
additional strategy, in addition to suppressing the causative bacteria, for treating
periodontal diseases. The current understanding of periodontal disease etiology
and pathogenesis emphasizes the role of the host in tissue destruction.
The new concept is based on the antigen-antibody reaction. Plaque accumulation will
cause an immune response. Leukocytes and immunoglobulins are released and
eventually cause gingivitis.
As mentioned before, inhibition of certain host response pathways is an additional
strategy in facing gingivitis. How is it done? By anti-inflammatory drugs like
ibuprofen. Using this way, plaque is there, but it is not causing any problems as the
inflammatory pathway is inhibited by the drug; the antigen-antibody reaction is
stopped.
This is not a preferred method, as it causes gastric side effects
Good luck