Perio Lec 7 Chemotherapeutic Agents &Medically-Compromised

5/28/2018 Perio Lec 7 Chemotherapeutic Agents &Medically-Compromised

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This lecture includes two topics :1-Chemotherapeutic agents

2-Medically compromised pts

*Chemotherapeutic agents*

We'll continue with chemotherapeutic agents and we said these agents are chemicalsubstances provide a clinical therapeutic benefit & divided into :

AntisepticsDisinfectantsAnti-plaqueAnti-gingivitisAntibiotics .

** Subginigival irrigation ( slides pg 14)When we advise our pt to rinse using a mouth wash , we don't expect this MW will go more

than 1-2 mm beyond the gingival margin , however for such a case we can use an irrigantvia canula & we'll reach 7-8mm "pocket penetration" .

** it's very important to know that the benefit we gain from subgingival irrigation is notbecause of the substance we use during irrigation ! You may use normal saline and it will bevery beneficial and u'll have good resultsSo irrigation is good (we need the flushing effect of the technique) whether u usedantibiotics, normal saline or whatever. Sometimes in certain cases (Aggressiveperiodontitis) u may need irrigtion with ab to get good results !** SUbgingival irrigation with ab may help also in (esp.before instrumentation) :1) reducing the incidence of bacteremia.Esp. for pts with high risk for Endocarditis .

2)reducing the # of MO in aerosols.** Irrigant solutions used :*)Chlohexidine

**) Listerine"2nd line after CHX"***)Tetracycline & Povidone-Iodine*single administration isnot enogh at all ,teach ur pt how to use it at home so he can apply itmore times by himself.

CONTROLLED RELEASE AGENTS :

Substantivity for sustained & therapeutic dose ; this means these agents provideProlonged release "sustained" in addition they attemptto maintain drug levels withintherapeutic window to avoid potentially hazardous peaks in drug concentration following

ingestion .**many devices could be used : fibers , chips , gels & micropheres. These agents will beabsorbed and released in the body under specific stimuli/specific period .** mainly used for deep pockets after finishing with conventional treatment -debridement,

scaling, root planing ...etc- .. but you should consider that we don't use it if we have manypockets it would be better if u use irrigation with ab for such a case .. so , controlled release

agents are used for single deep pocket .** an example for these agents is "Perio chip" which contains 2.5 mg chlorhexidinegluconate. perio chip: (-) PD depths, (+) CAL , (-) bleeding.

HOST MODULATION DRUGS:

In general, destruction of the periodontium in periodontal diseases comes directly from

(host response) & indirectly from (bacteria) , so to stop the destruction we need to stop thehost response effect.An important factor in host response against perio disease >>> Prostaglandins (PGs)production !


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PGs are released from macrophages during inflammation causing bone destruction in periodiseases , esp (PGE2).

So host modulation drugs are used to stop host response effect & these drugs include :

1) NSAIDs : (eg : Aspirin )They mainly inhibit PGs production & slow periodontal bone loss .

MOA :

Plasma membrane contains phospholipids , during injury phospholipase A converts thesephospholipids into Archidonic acid which helps in releasing Cox1 (responsibe for platletproduction) & Cox 2 (responsible for PGs production that induce pain+inflammation+boneresorption)NSAIDs work on inhibiting the production of cox 1 (sothat it is considered as antiplatlet) &

inhibit cox 2 (considered as host modulation drug).

2) Tetracyclin : (anti-collagenase)Inhibit the activity of host derived collagenases,gelatinases&elastases .

Several types of tetracyclins are available: tetracyclin, Doxycyclin & Minocyclin , sameMOA for all of these drugs .Doxycyclin is very important in perio clinics ,it could be applied in many ways such as;local gels after scaling and root planning this method is called (LDD=local delievry drug),


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this method isn't considered as host modulation instead they found out that usingDoxycyclin in a systemic way with very low concentration 20 mg (Periostat) for a long

period will give anti collagenase effect so we control host response effect on tissues. Somestudies said that such drugs may induce resistance and others denied that . Still these drugs

are very good and commonly used .

The doctor didn't say anything about those next slides so I add them as they are :

How to write a prescription? Write clearly Preferably use scientific name Write the form of medication Write the quantity of the medication Write the method of application Write the duration of intake Write the doze

Write the precautions Use accurate abbreviations

Form of medication Oral Route: Capsules, syrup, tablets Intra-oral topical use: Rinses, lozenges,ointment, gel External use: ointment, gel, cream Injections: intra-muscular (IM), intravenous(IV), subcutaneous (SC)

Quantity prescribed Specially in restricted medications For pain medications (30 tab, 20 caps) Know the proper dosage to know theproper quantities. Example: Amoxicillin isprescribed for intra-oral infections for oneweek, three times daily 7 X 3 = 21 capsules Children syrup: know the concentration

per ml. and the child weight Medications and doses that require lesscompliance, especially for long-term use

Abbreviations commonly used b.i.d.: used twice daily (every 12 hours) t.i.d.: three times daily (every 8 hours) q.i.d.: four times daily h.s.: at bed time Stat.: immediately d.: once daily

p.c.: after meal p.r.n.: when needed Caps.=capsules tab= tablets


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Examples: amoxicillinPrescribed for adults as 250 mg and 500mg capsulesAmoxicillin 500 mg caps (22caps)2 stat then 1 x 3 x 7 p.c. OR;2 stat then 1 t.i.d. p.c. 7 days

Examples of commonly usedmedications in dentistry:Pain IbuprofenSyrup (for children)Tablets (200, 400, 600, 800 mg), or

gelcap (Doloraz 400)Maximum dose per day for healthy adult:2400 mg per 24 hoursPrescribed t.i.d.Post surgery: depending on severity 400-800 t.i.d. p.c.

Commonly used medications indentistry:Pain

Paracetamol (acetomenophin)Children: syrup, suppsAdults: tablets 250, 500, 1000 mg, effervescent tabletsCould come with caffiene or combination of aspirinand caffiene (Tylenol preps, USA)New fast release: Panadol Actifast (500 mg)Maximum dose per day for healthy adult: 4 grams per24 hoursHelpful for patients with gastric irritation, asthma,

contraindications for NSAIDs.

Examples:Ibuprofen 400 mg tabs 30

1-2 tab t.i.d. p.r.n. p.c.Or; 1-2 tab x 3 p.r.n. p.c.Paracetamol 500 mg tabs 401-2 tab q.i.d. p.r.n. p.c.Or, 1-2 x 4 x 3 then p.r.n.

Chlorhexidine gluconate mouthwash(mouth rinse) European preps (BP, 0.2%), US preps (USP, 0.12%) Prescribed post-surgical, for patients with challangingoral cavity conditions, severe inflammation, physicallyimpairedpatients, nifedipine-induced gingivalenlargement and patients with poor mechanical abilityto remove calculus) The duration and frequency of use not agreed upon(days depend on indication) Common prescription in our clinic is b.i.d. rinse

Chlorhexidine gluconate mouthwash


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(mouth rinse) example

Chlorhexidine 0.2% mouthwash I bottle Rinse 2 minutes, 30 minutes afterbrushing 10 ml x 2x 14

Antibiotics Many, many Periodontics: aggressive peridontitisFor adults: amoxicillin 500 mg caps (2 stat)and Metronidazole 250 mg tabs (t.i.d. p.c. 7days)

Or Doxycycline 100 mg (2 stat then 1X1X20)

* Periodontal treatment in medically compromisedPatients *

In perio we use to treat only patients with teeth, that was before introduction of implants,after implants were introduced perio treatment starts to deal with dentate patients andpatients with implants (which in most of the time are older age group), because of that periotreatment is now dealing with all age groups and usually the older patients are susceptible tobe medically compromised patients.

The problem is that the vast majority of the killer diseases in the third world countries are thenon-communicable chronic diseases(Ex; diabetes , hypertension , renal problems), while in

the first world countries it not the same (for example in Japan the infectious diseases areone of the most common causes of death in the old age group ).

So Our Goals in treating medically compromised patients: is to evaluate any source ofinfection that may compromise successful periodontal therapy and restore optimal oralhealth and function thorough :1-Medical and dental history "including medications".2- Complete periodontal /dental charting.3- Physician consultation to corroborate medical history and coordinate dental and medicalcare.4- Arrange treatment initiate preventive therapy.5-Arrange follow up.

*if your case diagnosis was associated with a medical problem then you have to make moreinvestigations related to that problem like (radio graphs, lab tests . Etc).

medically compromised patients : Cardiovascular diseases Endocrine Disorders Renal Diseases Liver Diseases Pulmonary Diseases Immunosuppression and Chemotherapy Prosthetic Joint Replacement Hemorrhagic Disorders Infectious Diseases


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We will start with the Cardiovascular diseases like:

Hypertension.

Cerebrovascular Accident.

Ischemic heart diseases.

Infective Endocarditis

* Hypertension:Hypertensive patients are divided into two types:

-Primary: about 95 % of hypertensive patients are primary type, in this type there will be aproblem in the cardiovascular system itself ,that means there is no underlying cause in anyother system .

-Secondary: there is an underlying etiology, like: problems in endocrine, renal problems &neurogenic disorders, so to treat hypertension you have to treat the underlying problem, andthen hypertension will be resolved.Note:Most of hypertension patients don't know that they have this problem because in early stagesof hypertension patient tend to be asymptomatic, so you as a Dentist should be able todiagnose such patients. Recently, there is an increased in number of patients diagnosed withdiabetes at dental clinic, so we all have to know how to measure blood pressure & how tomake sure this is hypertensive patients or not, and of course one measurement isn't enough.If not identified or diagnosed, and treated. Hypertension may persist and increase in severity,leading eventually to coronary artery disease, angina, myocardial infarction, congestiveheart failure, cerebrovascular accident, or kidney failure.

Classification of hypertension :


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So what are your concerns when you treat a hypertensive patient?A-Stress:As long as you minimize stress, your dental treatment for a hypertensive patient isconsidered to be generally safe, so How to minimize stress??*appointment should be as short as possible ,the doctor says not more than one hour .*dont leave blooded gauze in front of the patient.*try to talk to your patient while treating him / her.*It was thought that morning is best time for appointment, however they found that blood

noon, so aftermiddayssure will be high after wake up. Blood pressure peaks atpreconsidered being the best time for hypertensive patients.B- Medication:The antihypertension drugs have many side effects thats should be in our concern like:

1. Postural hypotension .2. Depression .3. Nausea .4. Oral dryness .5. Lichenoid drug reactions .6. Gingival overgrowth (phenytoin, cyclosporine, and nifedipine) .7. you have to make sure if your patient is taking any anti coagulant drugs

(aspirin warfarin) and you should know how to deal with it before any surgicaltreatment.

C- Local anesthesia:Because epinephrine is a vasoconstrictor it may cause elevation in the blood presser, so

the smallest possible dose of epinephrine should be used, if your treatment is less than 30minutes you can use local anesthesia without epinephrine.

It is important to minimize pain (to avoid an increase in endogenous epinephrine). To avoid intravascular injections, aspiration before injection of local anesthetics is

critical. Try to give infiltrations, and avoid I.D block.

The record stopped here so I add the last pages from the 2009 script

Done by :

Hanady al masriAbdallah al- zireeni


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"from 2009 script"Infective endocarditits

Old name bacterial endocarditis , but recently they foundother microorganism as causative.

Difinition________________________________

Microorganisms colonize the damaged endocardium orheart valves..

aetiology________________________________

a-hemolytic streptococci (e.g., Streptococcusviridans). However, nonstreptococcal organismsoften found in the periodontal pocket havebeen increasingly implicated, including Eikenella

corrodens, Actinobacillusactinomycetemcomitans, Capnocytophaga, andLactobacillus species.

a-hemolytic streptococci present in oral cavity ,but itisn't considered as periodontal pathogen .recentlyevidence that actinomycetemcomitans are found ininfective endocarditits plaque & make embolism and allthe problem.

The effect of periodontal treatment starting fromprobing, scaling, root planning sometimes polishing allthese makes transient bacteremia.

]6[


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according to American Heart Association (AHA)recommends antibiotic prophylaxisbeforeprocedures associated with significant bleeding from

hard or soft tissues, periodontal surgery, scalingand Professional teeth cleaning.

Remember!

Prophylactic means treatment before the diseaseestablished, cause bleeding need prophylactic .

bacteremia may occur even in the absence ofdental procedures

-in patient with poor oral hygiene they havespontaneous bleeding even with breathing

Periodontics and IE:

AHA states that patients who are at risk for IEShould establish and maintain the best possible oralhealth to reduce potential sources of bacterial seeding.

According to AHA new guidelines 2007All Dental procedures that involve manipulationof Gingival tissue or the periapical region of teeth

or Perforation of the oral mucosa needprophylactic Antibiotic coverage.

The following procedures and events donot Need prophylaxis:

Routine anesthetic injections through non infectedtissue,

Taking dental radiographs,]7[


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Placement of removable prosthodontic ororthodontic appliances,

Adjustment of orthodontic appliances,Placement of orthodontic brackets,Shedding of deciduous teeth,

Bleeding from trauma to the lips or oral mucosa.

Management________________________________

Define the susceptible patient. (careful medical history)

Cardiac Conditions Associated for Which we shouldgive Prophylaxis for: (Dr Malek didnt read them buthere they are: )

Prosthetic cardiac valve Previous IE Congenital heart disease (CHD) Unrepaired cyanotic CHD, including palliative shunts Completely repaired congenital heart defect with

prosthetic material or device, whether placed bysurgery or by catheter intervention, during the first

6 months after the procedure Repaired CHD with residual defects at the site or

adjacent to the site of a prosthetic patch orprosthetic device (which inhibit endothelialization)

So for the management we have:Define the susceptible patient.

Provide oral hygiene instruction.

Prophylactic Antibiotics.

]8[


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This table shows the types of prophylacticantibiotics and below it are some notes:

Route of administration can be orally, IV, IM or others.The best till now is Amoxicillin (around 2 grams)If patient is allergic to penicillin we can give other

antibiotics like clindamycin or others.In general we give 2 grams one hour or 30 min before

treatment in order to have the antibiotic in reasonableconcentration in the blood.

Next in the management of Infective Endocarditis (IE):Eliminate the infection associated with periodontaldisease.

Teeth with severe periodontitis and a poorprognosis may require extraction: (hopeless teeth inthose patients are better be extracted)

All periodontal treatment procedures (including

probing) require antibiotic prophylaxis

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From now on, in the clinic you can't perform probingbefore proper history taking and making sure the patienthas no risk for IE, only then you can start probing! Andyou will be responsible for this in the clinic so be careful!

And the Dr will be strict about this!

Pretreatment chlorohexidine mouth washes.

Important note: Before you start scaling, ask the

dispensary for chlorhexidine mouth wash, dip somegauze in it, and wipe the whole area with it, this wayyou can reduce up to 80% of the bacteria bulk, by thissimple procedure you will also wipe away all the plaquein the area.

Numerous procedures may be accomplished ateach appointment.

Post-operative antibiotics: Some times indicatedwhen periodontic surgery is performed, and thepatient is still bleeding, so the risk of bacteremia isstill there even when the patient leaves, so if wegave him 2 grams pre-op we give him 500 gramsprophylactic antibiotic post-op for 2 or 3 days until hecomes back to remove the sutures.

It's debatable if removing suturesneeds prophylactic antibiotic or not in

case of patients at risk of IE.

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We have so far covered hypertension and IE fromthe cardiovascular diseases, Dr. Malek will provide uswith summaries about the rest and he said we should

read them as they are important.

Endocrine isorder

DiabetesHypoglycemiaThyroid and Parathyroid DisordersAdrenal Insufficiency

Diabetes

_______________________

Dr asked a question:

What is the normal fasting blood glucose level?No one answered, and the Dr didn't answer as

well, the references in the internet give manyranges but the most repeatable is (80-110mg/dL), however the Dr mentioned that we took

these things in other courses like medicine andsurgery, and that when he asks in the exam hewants the answers to be from what he says andhe is not responsible for what we take in othercourses. Again you should know these numbers(normal blood glucose level and so on).

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In diabetes we have:

Increased blood glucose level

Absolute or relative deficiency of insulin: Tissuesbecome resistant to insulin due to problems in insulinreceptors.

It has two types: insulin dependent and non-insulin dependent.

Now problems are faced in the undiagnosed patients

(some research says that more than 50% of thecommunity has diabetes, so the patient should be carefuland watch out for signs that can help diagnose diabeticpatients).

Intraoral signs of undiagnosed or poorlycontrolled diabetes GingivitisAlveolar bone resorption Xerostomia Delayed wound healing Pulpitis in non carious teeth Burning sensationAcetone smell in breath (from ketone bodies).

Dr said Multiple abscess as well

Thorough history should be taken, and you shouldconcentrate on family history in those patients even ifhe/she are not diagnosed as a diabetic patients and thenyou should:

Consult the patient's physician

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Analyze laboratory tests (like fasting bloodglucose test or others)

Rule out acute orofacial infection or severe dentalinfection and multiple abscesses (whenever you seemultiple abscesses in the patient's mouth youshould directly think about diabetes)

Management of diabetics

o Oral hygiene instructions,

o Mechanical debridement to remove localfactors,o Regular maintenance

o Periodontal infection may worsen glycemic control, andshould be managed aggressively (we mentioned beforethat the relation between periodontitis and diabetesare two-way, periodontitis affect diabetes by increasing

the resistance for insulin and diabetes on the otherhand affects periodontitis and worsens it)

oYou should always check HbA1c (border line ofHbA1c is 6.5)

o Systemic antibiotics are not needed routinely,

o Tetracycline antibiotics in combination with scalingand root planing may positively influence glycemiccontrol (in chronic periodontitis I can give antibiotics for

diabetic patients if it was a severe case)o Prophylactic antibiotics (poor glycemic control )

o Frequent reevaluation after active therapy (to makesure there is no recurrence of the disease)

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During periodontal treatment :

o Check blood glucose before any long procedure toget a baseline level (to avoid hypoglycemia during

treatment).

o Patients with blood glucose levels at or below thelower end of normal (70 mg/dl) before theprocedure may become hypoglycemicintraoperatively.

oAsk patients to attend to the clinic after havingBreakfast.

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Perio Lec 7 Chemotherapeutic Agents &Medically-Compromised