Antibiotic Adjuncts To Perio treatment

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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