USE OF ANTIBIOTICS IN

PERIODONTAL THERAPY

CONTENTS
INTRODUCTION
CLASSIFICATION OF ANTIBIOTIC USED IN
PERIODONTAL THERAPY
INDICATIONS
SYSTEMIC ADMINISTRATION OF ANTIBIOTICS
SERIAL AND COMBINATION ANTIBIOTIC THERAPY
CONCLUSION

Introduction
Antibiotics are the substances produced by
microorganism,which
selectively suppress the growth of
or kill other microorganisms, generally at low concentrations.
They are naturally occurring, semisynthetic, or synthetic type
of
antinfective agents.
The term antibiotic was coined by SELMAN WAKSMAN in 1943.
Penicillin- 1st natural antibiotic discovered by Alexander
Fleming in 1928.

Classification

2.According to type of action

Primary bactericidal: Penicillins, Cephalosporins ,
Aminoglycosides, Metronidazole
Primary bacteriostatic: Tetracycline, Erythromycin,
Clindamycin,sulfonamides

Classification
3.According to mechanism of action-

Interference with cell wall synthesis: Penicillins, Cephalosporins

Inhibition of protein synthesis and impairment of function of
ribosomes: Tetracyclines, Macrolides, Clindamycin
Interfere with transcription/translation of genetic information
(misreading of mRNA code): Metronidazole, Ciprofloxacin
4.According to routes of administrationSystemic(oral)
Local(Topical)

Indications
1.Chronic advanced periodontitis
2. Localized aggressive periodontitis.
3. Generalized aggressive periodontitis.
4. Periodontitis modified by systemic disease
5. Periodontitis as a manifestation of
systemic disease
6. Refractory periodontitis.
7. Necrotizing ulcerative gingivitis and
periodontitis
8. Pockets (>5 mm), continued attachment
loss
9. Gingival and periodontal abscess.

Systemic administration of antibiotics

The treatment of periodontal diseases is based on the infectious
nature of these diseases.
Ideally, the causative microorganism should be identified and the most
effective agent selected using antibiotic sensitivity tests.
An ideal antibiotic for use in prevention & treatment of periodontal
disease should be:
-specific for periodontal pathogen
-allogenic and non-toxic
-substantive
-not in general used for t/t of any other disease
-inexpensive

Tetracycline
TRADE NAMES -Terramycin, Achromycin
DOSE
Tetracycline 250mg/day qid
Minocycline 200mg/day bid
Doxycycline 200mg/day od
MOA

USES

-Inhibition of protein synthesis by binding to 30s ribosome

-Primarily bacteriostatic broad spectrum antibiotic
-Localized aggressive periodontitis
-Refractory periodontitis
-Periodontal and gingival abscess

Tetracycline
CI

-Pregnancy,Lactation
-Children below 8 yrs

ADR

-Tooth discoloration
-Enamel hypoplasia
-GI disturbance
-Hepatic & renal toxicity
-Superinfection

DRUG INTERACTION

-Oral contraceptives
-Penicillin
-Oral anticoagulant- depress plasma prothrombin activity

Metronidazole
TRADE NAMES Metroygyl, Flagyl
DOSE

MOA

250mg tid for 7 days

-Interferes with transcription/translation of genetic
information (misreading of mRNA code)
-active against anaerobes (bactericidal)

USES
-Chronic Periodontitis
-Aggressive Periodontitis
-Refractory Periodontitis
-ANUG

Metronidazole
CI
ADR

-Pregnancy
-Blood disorders
-Metallic taste
-Glossitis
-N/V,abdominal pain

Drug Interaction
-Alcohol- antabuse effect
-Warfarin & Other anticoagulants-PT

Penicillin
TRADE NAMES Amox, Augmentin
DOSE
Amoxicillin 500mg tid for 8 days
Augmentin 375mg tid for 7 days
Augmentin 625mg bid for 7 days
MOA
-Interfere with cell wall synthesis, bactericidal
-Excellent oral absorption
USES
-Localized & Generalized aggressive periodontitis
-LAP & Refractory periodontitis

Penicillin
CI
ADR

-Hypersensitivity reaction
-Diarrhoea
-Allergic reactions

Drug Interaction
-Aminoglycoside inactivates penicillin

Penicillin
Specific agents:
1.Amoxicillin- Susceptible to penicillinase
2.Amoxicillin-Clavulanate Potassium
(Augmentin)
-resistant to penicillinase enzyme
produced by some bacteria
-halts alveolar bone loss in periodontal
disease

Cephalosporin
TRADE NAME Alcephin
DOSE
2-6gm daily in 2-3 divided doses
MOA & USE
same as penicillin
But inferior to penicillin in their range of action
Resistant to number of- lactamases normally active against penicillin
CI
-Hypersensitivity
-Renal failure
ADR
-Allergic reactions(rashes, urticaria), fever,GI upset
-Candidiasis
-Transient Splenomegaly

Clindamycin
TRADE NAMES Clincin,Dalcap
DOSE

150mg qid for 10 days

300mg bid for 8 days

MOA
-Inhibits protein synthesis by binding to
50s ribosome
-effective against anaerobes
USES
-Refractory periodontitis (with tetracycline therapy)
-Patients allergic to penicillin

Clindamycin
CI

-Hypersensitivity
-Patient with H/O Colitis

ADR
-Pseudomembranous colitis
-Diarrhoea
-Abdominal pain
-Liver diseases

Ciprofloxacin
TRADE NAMES Ciplox,Cipin
DOSE 250-500mg bid
MOA

USES

- Inhibits bacterial DNA replication, bactericidal

- active against gram negative rods
- Promotes periodontal health associated microbial
flora as it has minimal effect on streptococcus
species
- Recurrent Periodontitis
- ANUG

Ciprofloxacin
- At present, it is the only antibiotic to which all strains of A.
actinomycetemcomitans are susceptible.
CI

-Hypersensitivity
-Pregnancy
-Pre-pubertal children

ADR
-Nausea
-Headache
-Metallic taste
-Abdominal discomfort, diarrhoea

Macrolides
TRADE NAMES Althrocin,Erythrocin
DOSE
MOA

USES

500mg qd for 3 days(Azithromycin)

250-500mg tid
-Inhibits protein synthesis by binding to 50s
ribosomes
-bacteriostatic or bactericidal, depending upon the
concentration
- Refractory periodontitis
- As a substitute to penicillin (doesnt cause hypersensitivity rxn)

Macrolides
CI

-Hepatic dysfunction (Erythromycin)

ADR
-Stomatitis
-Diarrhoea
-Jaundice
Drug Interaction
-Interferes with action of clindamycin & chloramphenicol
-plasma level,toxicity when administered with
theophylline, warfarin & cyclosporin

Macrolides
Specific agents:
1)Erythromycin
-does not concentrate in GCF, not effective against most putative
periodontal pathogens
2)Azithromycin
-concentration is higher in periodontal lesions
3)Spiramycin
-active against gram positive organisms
-excreted in high concentrations in saliva

Serial & Combination Antibiotic Therapy

Rationale:
Periodontal infections may contain wide diversity of
bateria(aerobic,anaerobic,gm +ve and ve).

No single antibiotic is effective against all putative pathogens.

Hence, it may be necessary to use more than one antibiotic, either serially
or in combination.
Antibiotic susceptibility testing performed.

Serial & Combination Antibiotic Therapy

1.Metronidazole + Amoxicillin or Augmentin
-Dose 250mg each tds
-Indication - Aggressive periodontitis
2.Metronidazole + Ciprofloxacin
-Dose 500mg each
-Indication Refractory Periodontitis
(as metronidazole targets obligate anaerobes while ciprofloxacin
targets facultative anaerobes)

Conclusion
Although mechanical periodontal treatment alone improves clinical
conditions sufficiently in most cases, adjunctive antibiotics, delivered
either systemically or locally, can enhance the effect of therapy.
Systemic antibiotics may be useful adjunct to the mechanical treatment
of aggressive forms of periodontitis.
Localized non-responding sites and localized recurrent disease may be
treated with locally delivered antibiotics.
To limit the development of microbial antibiotic resistance and to avoid
risk of unwanted systemic effects, a precautionary, restrictive attitude
towards using antibiotics is essential.

References
Carranzas Clinical Periodontology 10thedition
Clinical Periodontolgy n Implant Dentistry5thedition
Google

MCQS.
Which of following drug is used in patient with
periodontitis refractory to tetracycline therapy?
a.Augmentin
b.Doxycycline
c.Clindamycin
d.Metronidazole

MCQS
Which of following arrest alveolar bone loss in
patient with periodontal disease?
a.Clindamycin
b.Amoxicillin- clavulanate potassium
c.Tertacycline
d.All

MCQS
Only antibiotic in periodontal therapy to which all strains of A.
actinomycetemcomitans are susceptible?
a.Amoxicillin
b.Tetracycline
c.Metronidazole
d.ciprofloxacin