ANTIBIOTIC ADJUNCTS TO PERIO DONTAL TREATMENT

Properties of an Ideal Antibiotic

1. 2. 3. 4. 5. 6. 7.

Bacterial specificity Should not produce resistant strains Does not cause allergy or toxicity Does not cause other side effects Does not eliminate normal oral flora Cost effective Hence the ideal has not been found!

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. gingivalis T. denticola

B. forsythus
P. intermedia E. nodatum

Spirochetes

PERIODONTAL PATHOGENESIS DEPEND 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
PEN G/ PEN V

MACROLIDE ORODENTAL INFECTIONS

AMPI/ AMOXY

CLINDA

CEPHA

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 If client cant abstain from alcohol

Doxycycline may be substituted for metronidazole

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 alone Mean 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 PERIODONTOLOGYSHANTHIPRIYA REDDY WWW.WIKIPEDIA.COM WWW.CLINICS OF NORTH AMERICA.ORG