Role of Anti- Microbials in Periodontal Diseases

Dr. Faran FarooqHouse officer

Periodontology department

Objectives• Chemotherapeutic agents in periodontal diseases.• Contribution of Antimicrobials in Periodontal diseases.• Brief knowledge of Antimicrobials used in Periodontal

diseases.

Pathogenesis of Periodontal Diseases

Chemotherapeutic Agents• Anti-Infective Agents “Agent that works by reducing the number of bacteria present”

• Antibiotics/Antimicrobial Agents “Naturally occurring synthetic or semi synthetic type of anti-infective agents that destroy or inhibits the growth of selective micro-organism generally at low concentration.”

• Antiseptic Agents “Chemical antimicrobial agent applied topically or sub-gingivally to mucous membrane wounds or intact dermal surfaces to destroy micro-organism or inhibit their reproduction or metabolism.”

Antibiotics/Antimicrobial Agents

• SYSTEMIC ADMINISTRATION• LOCAL ADMINISTRATION

SYSTEMIC ADMINISTRATION

• May be a necessary adjunct in controlling bacterial infection because bacteria can invade periodontal tissues making mechanical therapy alone sometimes ineffective.

• Antibiotics provide a useful adjunct to root planning, which by itself may not remove all subgingival deposits and certainly would not affect any invading organisms that had already penetrated the SOFT TISSUE.

Contribution of Antibiotics

• Systemic antimicrobials are released from the pocket wall into the GCF.

• The susceptibility of bacteria to the antibiotics may be the key to the efficacy of systemic antibiotics in the treatment.

• Systemic antimicrobial therapy should be an adjunct to mechanical a comprehensive periodontal treatment plan.

• The antibiotic required 500 times greater strength then systemic therapeutic dose to be effective against the bacteria arranged in intact BIOFILMS

• It is therefore important to disrupt the biofilm physically.

Health

Oral hygieneRoot debridement

Supportive periodontal therapySurgical access for root debridement

Regenerative therapy

ANTIBIOTICS as indicated by microbial analysis

Aggressive, refractory or

medically related periodontitis

Chronic periodont

itis

Microbial analysis

Ineffective Effective

Supportive periodontal treatment

Guideline for the use of antimicrobial therapy

INDICATIONS FOR ANTIBIOTICS IN PERIODONTAL THERAPY

• local infection of a periodontal abscess can spread within tissue planes to cause marked facial swelling and systemic involvement

• Acute Necrotizing Ulcerative Gingivitis ANUG• Multiple abscess formation and gross periodontal

infection• Localized aggressive periodontitis LAP

IDEAL ANTIBIOTIC for periodontal disease

• Used in prevention & and treatment of periodontal disease• Specific for periodontal pathogens• Allogenic• Non toxic • Substantive • Not in general use for treatment of other disease.• inexpensive

CURRENTLYNO SUCH ANTIBIOTIC EXIST!!!!!!

So what????• Oral bacteria are susceptible to many antibiotics.• Unfortunately there is no single antibiotic i.e. (no “silver

bullet”) at concentration achieved in body fluids that inhibit all putative periodontal pathogens.

• Indeed a combination of antibiotics may be necessary to eliminate putative pathogens from periodontal pockets.

Selection of an ANTIBIOTIC

• Patients’ clinical status• History of the disease• Clinical signs & symptoms• Radiographic aid• Microbiologic sampling (if possible)Plaque sampling is done by the help of paper points

Common Antibiotics RegimensAntimicrobial Agent Regimen Dosage/Duration

Amoxicillin 500mg TDS for 8 days

Azithromycin 500mg OD for 4-7 days

Ciprofloxacin 500mg BD for 8 days

Clindamycin 300mg TDS for 10 days

Doxycycline/minocycline 100-200mg OD for 21 days

Metronidazole 500mg TDS for 8 days

Metronidazole + Amoxicillin

250mg f each TDS for 8 days

Metronidazole + Ciprofloxacin

500mg of each BD for 8 days

TETRACYCLINES Actisite , Robitet 500

• Produced from Streptomyces.• Bacteriostatic.• Protein synthesis inhibitor. (30s microsomal subunit)• Effective against multiplying bacteria.• Broad spectrum!! Activity against both Gram-positive

and Gram negative species • Concentration In GCF is 2-10 times than in serum.

• Investigated as an important in adjunct in LAP• Activity against A.actinomycetemcomitans• Dual action!!! Antimicrobial + host modulation (inhibit

Collagenase)• So! Reduce bone destruction & Aid regeneration.

Minocycline [cinocid , cycloxin] Adult periodontitis Spirochetes & motile rods 200mg/day for 21 days Less phototoxicity , renal toxicity than tetracycline. Reversible vertigo is one of the side effect

DoxycyclineSimilar spectrum as minocycline Can be given OD so better compliance100mg OD for 21 days.Marked anti-collagenase effect.

Vibramycin 100mg Nordox

Ardox

Metronidazole• Nitromidazole compound • Bactericidal • Disrupt bacterial DNA synthesis.• The antibacterial activity against anaerobic cocci,

anaerobic Gram - negative bacilli, and anaerobic Gram - positive bacilli

Flagyl 400mg, 200mgGramex 400mg

• effective against A.actinomycetemcomitans in combination with other antibiotics.

• Also effective against anaerobes such as porphyromonas gingivalis & provetella intermedia

• Successfully used to treat ANUG• Chronic periodontitis, aggressive periodontitis,

clinically significant gingivitis.

• 750-1000mg/day for 2 weeks reduces the anaerobic flora & decreases histopathologic signs of periodontitis.

• Most common regimen is 250mg TDS for 7 days.

• Cramps , nausea , vomting results due to interaction with alcohol.

• Avoid alcohol.• Inhibits warafrin metabolism so avoid in patients with

anticoagulant therapy.• Avoid in patients taking LITHIUM• Metallic taste.

Penicillin• Bactericidal • Cell wall inhibitor.

Amoxicillin Aggressive periodontitis generalized & localized both500mg for 8 days.

Amoxil 250,500mg

Amoxicillin-clavulanic acidLAPRefractory periodontitis

Bacterial resistance to penicillin is a curse!!

Augmentin 375, 625 mg

10% of the patients are resistant to penicillin

Clindamycin • Anaerobic bacteria.• In case of penicillin allergy.• Recommended dosage 150mg QDS for 10days. 300mg BD for 8 days.• pseudomembranous colitis, diarrhea , GI upsets

CiprofloxacinCiprox , ciclox

• Quinolones.• Gram negative rods, all facultative & some anaerobic.• It is the only antibiotic to which all strains of

A.actinomycetemcomitans are susceptible• Nausea, metallic taste , abdominal discomfort• 500mg BD for 8 days with or without Metronidazole.

Macrolides • Bacteriostatic or bactericidal depending on concentration.Erythromycin , Spiramycin AzithromycinAnaerobes , gram negative bacilli.500mg OD for 4 -7 days

Zithromax Zmax

Azomax 250mg

Serial & Combination Antibiotic Therapy

• Bacteriostatic antibiotic (e.g. tetracycline) require rapidly dividing microorganism to be effective SO not function well if bactericidal antibiotic (e.g. amoxicillin) is given concurrently. They are best given serially.

Metronidazole + Ciprofloxacin (POWERFULL COMBINATION)effective against A.actinomycetemcomitansMetronidazole against obligate anaerobes.Ciprofloxacin against facultative anaerobes

Metronidazole + amoxicillin / Augmentin Adult localized periodontitis , refractory to tetracyclines.Additive effect against A.actinomycetemcomitans250mg of each TDS for 8 days.

LOCAL ADMINISTRATION

• Local delivery antibiotics are recommended as adjuncts to scaling and root debridement, and not as stand-alone treatments.

• Fewer side effects, and fewer chances of resistant bacteria forming

• The concentration of the antibiotic at the diseased site can be 100 times greater than taking the medication orally i.e systemically.

Tetracycline containing fibers Actisite®12.7 mg / 9 inchesWell tolerated , placed for 10 daysConcentration in GCF is 1300 Ugm/ml compared

to 4-8mg by sys. Administration.

Subgingival Doxycycline 10% doxycycline in a gel system (ATRIDOX)

Subgingival Minocycline ARESTIN Small spheres of minocycline 2% , a derivative

of tetracycline is very effective in killing the bacteria that are thought to cause periodontal disease

Subgingival MetronidazoleTopical medication containing oil based

metronidazole 25% dental gel.

Take Home Message

ALWAYS EVALUATE THE PATIENT FOR THE INDICATIONS TO ANTIBIOTIC THERAPY

Bibliography

Carranza’s Clinical periodontology 10th edition.