ANTIBIOTICS USED IN PERIODONTAL DISEASE

PRESENTED BY:DR. HAFSA SARA ZUBAIRBDS

OBJECTIVES:• What is periodontal disease? • How periodontal pockets are formed?

• How to treat periodontal pockets?

• What are antiinfective agents?

• Guidelines for use of antibiotics in periodontal therapy.

• systemic administration of antibiotics

• common antibiotics regimens to treat periodontal disease.

• Serial or combination antibiotics.

• Local delivery agents

WHAT IS PERIODONTAL DISEASE?

Periodontal disease refer to all the diseases of peridontium; this means that a periodontal disease is any pathological state that involves the supporting tissue of the teeth.

•Usually caused by bacterial infections.

HOW PERIODONTAL POCKETS ARE FORMED?

THIS SUPRAGINGIVAL PLAQUE BECOMES COMPLEX

AFTER TEETH HAVE BEEN CLEANED

BACTERIA BEGINS TO REATTACH AND FORM BIOFILM

EVENTUALLY BONE IS DESTROYED A PERIODONTAL POCKET IS FORMED

BACTERIAL GROWS IN APICAL DIRECTION AND BECOME SUBGINGIVAL

LEADING TO SUCCESSION OF BACTERIA

HOW TO TREAT PERIODONTAL POCKETS??

• BY MECHANICAL REMOVAL OF LOCAL FACTORS:calculusplaque

MECHANICAL REMOVAL INCLUDES:1. Manual instrumentation

a. Scalingb. root planing

2. Machine drive instrument Ultrasonic scalers

• THESE PROCEDURES ARE CONSIDERED TO BE ANTIINFECTIVE THERAPY

ANTIINFECTIVE AGENTS:

“A Anti-infective agent is a chemotherapeutic agent that act by reducing the number of bacteria present. It destroys or inhibits the growth of selective microorganisms .”

• Can be administered ORALLY OR LOCALLY.

•SYSTEMIC ADMINISTRATION OF ANTIBIOTICS controls bacterial infections.

•LOCAL ADMINISTRATION OF ANTIINFECTIVE AGENTS provide greater concentration directly to the infected area and reduce possible side effects.

GUIDELINES FOR THE USE OF ANTIBIOTICS IN PERIODONTAL THERAPY

Clinical diagnosis and situation dictate the need for possible antibiotic therapy.

Antibiotics should be selected based on patient’s medical and dental status ,current medications,and plaque sampling analysis.

Adjunct therapy has shown more benefits in periodontal treatment rather than alone therapy.

Biofilm should be disrupted physically so that antibiotics can access to periodontal pathogens

SYSTEMIC ADMINISTRATION OF ANTIBIOTICS

CATEGORY AGENT MAJOR FEATURES

Penicillin Amoxicillin

Augmentin

• Extended spectrum of antimicrobial activity; excellent oral absorption used systemically.• Extended against penicillinase producing microorganisms ; used systemically.

Tetracycline MinocyclineDoxacycline

Tetracycline

• effective against broad spectrum of microorganism; used systemically, applied locally ( subgingivally)• used systemically; applied locally.•Used in sub-antimicrobial dose for host modulation.

CATEGORY AGENT MAJOR FEATURES

Quinolone Ciprofloxacin • Effective against gram negative rods, promotes health associated microflora.

Macrolide Azithromycin • concentrate at site of inflammation; used systemically.

Lincomycin derivatives Clindamycin •Used in penicillase-allergic patients; effective against anaerobic bacteria; used systemically.

Nitroimidazole Metronidazole •Effective against anaerobic bacteria; used systemically and applied locally (subgingivally) as gel.

CONT……

COMMON ANTIBIOTICS REGIMENS USED TO TREAT PERIODONTAL DISEASE

SINGLE AGENT REGIMENS DOSAGE/DURATION

Amoxicillin 500mg Three times daily for eight days.

Azithromycin 500mg Once daily for 4-7 days

Ciprofloxacin 500mg Twice daily for 8 days

Clindamycin 300mg Three times daily 10 days

Doxacycline or minocycline 100-200mg Once daily for 21 days

Metronidazole 500mg Three times daily for 8 days

COMBINATION THERAPY REGIMENS DOSAGE/DURATION

Metronidazole + amoxicillin 250mg of each Three times daily for 8 days

Metronidazole + ciprofloxacin 500mg of each Twice daily for 8 days

MECHANISM OF ACTION

CLINICAL USE SIDE EFFECTS

Binds reversibly to 30s ribosome subunit

Blocks bacterial translocation.

This prevent binding of aminoacly tRNAs to A-site of the ribosome.

• used to treat:

- Aggressive periodontitis in children.

• GI disturbance• Photosensitivity• Hypersensitivity• Increase blood urea nitrogen• Blood dyscrasias• Dizziness• Headache• Tooth discoloration occurs when administered to children up to age 12 years.

TETRACYCLINE

MINOCYCLINE

MECHANISM OF ACTION

CLINICAL USE SIDE EFFECTS

Binds reversibly to 30s ribosome subunit

Blocks bacterial translocation.

This prevent binding of aminoacly tRNAs to A-site of the ribosome.

• Used to treat: - Adult periodontitis by suppressing spirochetes and motile rods.

• GI disturbance• Renal toxicity• Photo toxicity• Hypersensitivity• Blood dycrasias• Increase blood urea nitrogen• Dizziness• Headache• vertigo

DOXYCYCLINE:MECHANISM OF ACTION

CLINICAL USE SIDE EFFECTS

Binds reversibly to 30s ribosome subunit

Blocks bacterial translocation.

This prevent binding of aminoacyl tRNAs to A-site of the ribosome.

• Used to treat: - Adult periodontitis by suppressing spirochetes and motile rods

• GI disturbance• Photosensitivity• Hypersensitivity• Increase blood urea nitrogen• Blood dyscrasias• Dizziness• Headache• Tooth discoloration occurs when administered to children up to age 12 years.

..METRONIDAZOLE:

MECHANISM OF ACTION CLINICAL USE SIDE EFFECTS

Entry into the microorganism

Reductive activation by intracellular transport proteins- Metronidazole is reduced by the pyruvate:ferredoxin oxidoreductase system in the mitochondria of obligate anaerobes, which alters its chemical structure.

Reduced intermediate particle interacts with intracellular targets- Cytotoxic intermediate particles interact with host cell DNA, resulting in DNA strand breakage.

Breakdown of cytotoxic intermediate products

•Used to treat: - Gingivitis - ANUG - Chronic periodontitis - Aggressive periodontitis

• When combined with amoxicillin, metronidazole is used in the management of patient with LAP or refractory periodontitis.

• Has an antabuse effect when alcohol is ingested and can result in : - Cramps - Nausea - Vomiting - Metallic taste

• Alcohol products should be avoided.• pt undergoing anticoagulant therapy should avoid metronidazole.• should be avoided in pt who are taking lithium.

PENICILLINS:

MECHANISM OF ACTION

CLINICAL USE SIDE EFFECTS

It inhibit cell wall synthesis by following ways:

- Inactivates protien present on the bacterial cell membrane. - Inhibit transpeptidase catalayzed reaction. - By production of autolysins

There use in periodontal therapy does not appear to be justified.

• Allergic reactions• Hypersensitivity• Nephritis• Neurotocxicity• hematologic toxicity• Cation toxicity

CEPHALOSPORINS:

MECHANISM OF ACTION CLINICAL USE SIDE EFFECTS

It inhibit cell wall synthesis by following ways:

- Inactivates protien present on the bacterial cell membrane. - Inhibit transpeptidase catalayzed reaction. - By production of autolysins

Not used to treat dental related infections.

• Rash• fever• GI disturbance

CLINDAMYCIN:

MECHANISM OF ACTION

CLINICAL USE SIDE EFFECTS

Binds to 50s subunit

Inhibit protein synthesis

Used to treat - Periodontitis

• Diarrhea• Rash• Neutropenia

CIPROFLOXACIN:

MECHANISM OF ACTION CLINICAL USE SIDE EFFECTS

Inhibits bacterial folic acid synthesis thereby killing bacteria.

• may facilitate the establishment of microflora associated with periodontal health.

• Nausea• Headache• Metallic taste• Abdominal discomfort

MACROLIDES: (erythromycin, spiramycin, and azithromycin)MECHANISM OF ACTION CLINICAL USE SIDE EFFECTS

Binds irreversibly to a site of 50s subunit of bacterial ribosome

Inhibit the translocation step of protein synthesis

•Spiromycin is used as adjunct to periodontal treatment.• Azithromycin can be used to treat - Aggressive periodontitis - gingival enlargement

• Epigastric distress• ototoxicity• cholestatic jaundice

SERIAL OR COMBINATION ANTIBIOTIC THERAPY:

• In some cases it is necessary to use more then one antibiotic, either serially or in combination.

EXAMPLES:

• Metronidazole-amoxicillin and metronidazole-augmentin combination provide excellent elimination of organism in adult and LAP

• Metronidazole-ciprofloxacin is effective against A. actinomycetemcomitans

LOCAL DELIVERY AGENTS:• They control growth of bacteria on barrier membranes.

•AMERICAN ACADEMY OF PERIODONTAL STATED:

“ The clinician decisions to use LDA should be based upon clinical

findings, patient's dental and medical history, patient preference and advantages

and disadvantages of therapies.”

SUBGINGIVAL CHLORHEXIDINE:

This include:• Periochip is a small chip composed of:

• Biodegradable hydrolysed gelatin matrix• glycerin• water into which 2.5 chlorhexidine gluconate

has been incorporated per chip.• This system releases chlorhexidine and maintain

drug cocentration in GCF.• Chips biodegrades in 7-10days.

PLACEMENT OF CHLORHEXIDINE GLUCONATE CHIP.

TETRACYCLINE CONTAINING FIBRES:

•An ethylene/vinyl acetate copolymer fibre containing tetracycline 12.7mg per 9 inches.

•When packed into periodontal pocket it inhibit the growth of pathogens.

•Tetracyclin fibres reduce - probing depth - bleeding on probing - periodontal

pathogens

SUBGINGIVAL DOXYCYCLINE:

•Gel system using syringe with 10% doxycycline.

•It reduces:- probing depth- bleeding on probing- growth of oral pathogens

PLACEMENT OF 10% DEOXYCYCLINE GEL.

SUBGINGIVAL MINOCYCLINE:

• 2% minocycline is encapsulated into bioresorbable microspheres in a gel carrier.

•It reduces:- probing depth- bleeding on probing- growth of oral pathogens

PLACEMENT OF MINICYCLINE MICROSPHERE.

SUBGINGIVAL METRONIDAZOLE:

• contain oil-based metronidazole 25% dental gel.

•Applied in viscous consistency to the pockets.

•It reduces:- probing depth- bleeding on probing- growth of pathogens

REFRENCES:

CARRANZAIMAGES FROM GOOGLE