Dr. Diana Mostafa

!  Bacteria Biofilm Supragingival plaque

Continuous growing apically

Subgingival plaque

By toxic products(direct action) +immunological response (indirect action)

Bone destruction +

PD pocket

Periodontitis

!  Mechanical removal of bacterial plaque

!  by scaling and root planning “anti-infective therapy”

!  Manual or ultrasonic

!  Chemotheraputic agents “anti-infective agents”

!  Systemic or local

modulate host response + dec. no of bacteria

!  Decrease bone loss

i.e. adjunctive but not substitute

better

!  An ideal antibiotic for treatment of PD diseases should be:

1.  Specific for PD pathogens 2.  Non toxic 3.  Substantive 4.  Not in general use for Rx of other diseases 5.  Inexpensive

Ideal antibiotic for treatment of periodontal diseases

DOES NOT EXIST

" Ideally , the causative MO should be identified using

antibiotic-sensitivity test BUT It is difficult to identify specific etiologic MOs in PD dis.

!  Indications for microbial plaque testing include: 1.  Aggressive forms of PD dis. 2.  Purulent exudates(abscess) and continuous

attachment loss. 3.  Refractory PD dis. to standard mechanical

therapy. 4.  Periodontitis associated with sys. conditions

!  Acute infection(NUG & NUP) !  Abscess !  Aggressive periodontitis. !  Recurrent (Refractory) periodontitis.

ANTIBIOTIC PROPHYLAXIS (PREVENTION)

1- History or risk of infective endocarditis and heart defects. 2- Prosthetic cardiac valve. 3-Immunocomrized patients.

!  Tetracyclines(Minocycline , Doxycycline, Tetracycline)

!  Metronidazole !  Penicillins (Penicillin, Amoxicilline, Augmentin) !  Cephalosporins !  Clindamycin !  Ciprofloxacin !  Macrolides

!  Broad spectrum antibiotic !  Bacteriostatic…. against rapidly multiplying bacteria. !  Used to treat LAP and refractory cases. !  G+ve >> G-ve bacteria. !  Its conc. in the GCF is 2-10 times than in serum which make it

more effective for PD dis. (studies!! Tetracyclines in low conc. in GCF (2 -4µg/ml) are very effective against many PD pathogens)

Actions: 1.conc. In PD tissues. 2.Inhibit growth of A.a. 3.Anticollagenase effect!Inhibit tissue destruction!Aid in

bone regeneration. 4. Has anti-inflammatory action! suppress PMN activity.

Tetracycline have been investigated as adjunct in

the treatment of LAP, y? It is not advisable to describe long term regimens of

tetracycline ,y??? dt development of resistant bacterial strains + side effects

NOW , replaced More effective combination “amoxicillin + metronidazole“

!  Administration 250mg 4 times daily (qid).

!  Inexpensive but doubtful compliance. Side effects: GI disturbances, photosensitivity, hypersenstivity,

increased blood urea nitrogen(BUN),headache, tooth discoloration when administered to children under 12 years.(breast feeding mother-pregnant woman)

!  Suppresses spirochetes and motile rods. !  Given 100mg twice daily(bid) or 200mg per a day(qd) for 1

week facilitating compliance.

Side effects:

!  Similar to tetracycline BUT Less photosensitivity and renal toxicity.

!  Reversible vertigo. N.B Only tetracycline can discolor permanent teeth and

gingival tissues .

!  Has same spectrum as minocycline, but only given once daily(qd) more compliant!!

!  It is not altered the absorption of the Ca, metal ions, or antacids as other tetracycline

!  THE Most Photosensitive Agent in Tetracyclines family.

DOSES: 100 mg bid 1st day, then 100 mg qd OR 100mg qd or 50mg bid( GI upset) .

!  Bactericidal(kill) to anaerobic bact.including spirochetes because it disrupts the bacterial DNA synthesis.

!  Present in both serum and GCF

!  Effective against P. gingivalis & P. intermedia but not against A.a unless combined to other antibiotics!!!!

Used to treat: 1.  NUG. 2.  Chronic periodontitis. 3.  Aggressive periodontitis.

Doses: 1.  250mg 3 times daily(tid) for a week. Side effects: 1.  Antabuse interaction, when alcohol is ingested (cramp,

nausea, vomiting).

2.  Inhibits warfarin metabolism and anticoagulant drugs.

3.  Avoided in patients on lithium (psychiatric treatment).

4.  Metallic taste in mouth.

5.  Not recommended as mono-therapy.

!  β-lactam …Most widely used antibiotic. !  Inhibit bact. cell wall production ! bactericidal. Side effect: !  Bact. resistance !  Induce allergic reactions

Amoxicillin is semisynthetic penicillin with extended anti-infective

spectrum (G+ve, G-ve) Dose:500mg 3 times/ day(tid) for 8 days. Uses : for treatment of LAP & GAP.

Augmentin is combination = amoxicillin +clavulanate potassuim.

(resist pencillinase enz.) Uses: management of AP or refractory periodontitis. (It also arrests alv. Bone loss ) Dose : 625mg/ml 3 times per day for 8 days

!  Is similar in action and structure to penicillins !  Generally, it ISN’T used to treat dental infections,

because the penicillins are SUPERIOR in action against PD pathogenic .

Side effect: !  Patients allergic to penicillins must be considered

allergic to all beta-lactams. !  Rashes, urticaria, fever, and GI upset.

!  Effective against anaerobic bacteria on osseous tissues. in situations of penicillin allergy. in Rx of refractory periodontitis . Dose: 300 mg 2 times/day(bid) for 8 days Side effects: pseudomembranous colitis.(cramps and

diarrhea)

!  It is active against G-ve rods. !  It has minimal effect on Streptococcus species, which facilitates

the establishment of a microflora associated with PD health.

!  The only antibiotic that affects all strains of Aa. !  It also used in combination with Metronidazole. Side effect: !  Nausea , headache !  Metallic taste !  Inhibit the metabolism of theophylline (branchodilatotor)and

caffeine, concurrent administration can produce toxicity. !  Enhance warfarin effect and other anticoagulants.

!  Inhibit protein synthesis. !  Bacteriostatic or Bactericidal depending on

drug conc. and nature of MO. !  Macrolids used in periodontal Rx include

Erythromycin, Spiramycin ,and Azithromycin.

!  DOSES: 250mg/day for 5 days after an initial loading dose of 500mg.

Erythromycin

!  Not recommended ,Y??? 1.  Does not concentrate in GCF 2.  Not effective against most PD pathogens

Spiramycin "  Active against G+ve . "  Excreted in high conc. in saliva "  Has minimal effect on increasing attachment levels

Azithromycin Is effective against anaerobes and G-ve bacilli

It penetrates fibroblasts and phagocytes. It is transported to sites of inflammation by phagocytes, then released directly as the phagocytes rupture during phagocytosis.

WHEN both types of DRUGS are described, they are best given SERIALLY, not in COMBINATION .

example Bacteriostatic antibiotics(e.g., tetracycline) generally

require rapidly dividing MO to be effective. They do not function well if a bactericidal antibiotic (e.g., amoxicillin) is given concurrently.

Bacteriostatic Bactericidal Tetracycline

Penicillin

Clindamycin

Cephalosporin

Erythromycin

Metronidazole

Metronidazole+amoxicillin Metronidazole+Augmentin

Metronidazole+ciprofloxacin

excellent elimination of MO in LAP

(+ mech. Debridement)

powerful in the treatment of refractory periodontitis

Each:500mg BID for 8 days

- Eliminate pathogenic organisms -keep streptococcal microflora

!  Management of periodontitis

mechanical debridement +patients’ oral hygiene efforts + effective and safe systemic antibiotics

The use of antibiotic in treatment of gingivitis

is contraindicated. Y?? Bec. local factor can easily removed.

Misuse or overuse of prophylactic antiinfective agent

Increase bacteria resistance

Useless