Professional Documents
Culture Documents
ANTI-INFECTIVE
THERAPY
Bethel ,DMD
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DEFINITIONS
Chemotherapeutic agent: acts to reduce the
number of bacteria present.
ROUTE OF
ADMINISTRATION
Systemic: may be a necessary adjunct in controlling
bacterial infection.
SYSTEMIC ADMINISTRATION
OF ANTIBIOTICS
Treatment of periodontal disease is based on
infectious nature of the disease.
An ideal antibiotic for use in prevention and
treatment of periodontal disease:
1. Specific for perio. pathogens.
2. Nontoxic.
3. Inexpensive.
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SYSTEMIC ADMINISTRATION
OF ANTIBIOTICS
The treatment of the individual patient is based on:
1. Patients clinical status.
2. Nature of colonizing bacteria.
3. Ability of the agent to reach the site of infection.
4. Risks and benefits associated with the proposed
treatment.
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SYSTEMIC ADMINISTRATION
The clinician is OF ANTIBIOTICS
responsible for choosing the
correct antimicrobial agent.
Some adverse reactions include:
1. Allergic/anaphylactic reactions.
2. Superinfections of opportunistic bacteria.
3. Development of resistant bacteria.
4. Interaction with other medications.
5. Upset stomach.
6. Nausea.
7. Vomiting.
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TETRACYCLINES:
TETRACYCLINES:
Bacteriostatic.effective against rapidly multiplying
bacteria.
G+ve>>G-ve bacteria.
Concentration in gingival crevice 2-10 times in serum.
Long term regimens can develop resistant bacteria.
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TETRACYCLINE HCL
Administration 250mg 4 times daily (qid).
Inexpensive
Side effects: GI disturbances, photosensitivity, blood
urea nitrogen, tooth discoloration.
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MINOCYCLINE
Suppresses spirochetes and motile rods.
Given 200 mg/day for 1 week.
Less photosensitivity and renal toxicity.
Side effects: are similar to those of tetracycline
however there is increased incidence in
vertigo.
Only tetracycline that can discolor
permanently erupted teeth and gingival tissue
when administered orally.
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DOXYCYCLINE
METRONIDAZOLE
Nitroimidazole compound developed for protozoal
infection.
Bactericidal to anaerobic organisms because it disrupts
the bacterial DNA.
Effective against P.g and P.i but not the drug of choice
against A.a unless combined to other antibiotics!!!!
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Used to treat:
METRONIDAZOLE
1. Gingivitis.
2. Necrotizing ulcerative gingivitis/ NUG
3. Chronic periodontitis/CP
4. Aggressive periodontitis/AP
Doses:
1. 250mg 3 times daily(tid) for a week.
2. Arestien.(local delivery sustained release
form).
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METRONIDAZOLE
Side effects:
1. Antabuse effect when alcohal is ingested.
2. Inhibits warfarin metabolism.
3. Patient on anticoagulant should avoid it. b/c
prolongs prothrombin time.
4. Should be avoided in patients on lithium.
5. Metallic taste in mouth
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PENICILLINS
Most widely used antibiotic.
Inhibit bacterial cell wall production and so they are
bactericidal.
Induce allergic reactions and bacterial resistance.
Amoxicillin and amoxicillin-clavulanate potassium
(Augmentin).
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PENICILLINS
Amoxicillin is semisynthetic penicillin with extended
antiinfective spectrum (G+ve,G-ve)
Amoxicillin is for treatment of aggressive periodontitis
both localized and generalized forms.
Augmentin is used for management of LAP or refractory
periodontitis.
Amoxicillin: AP (LAP & GAP)
Augmentin: LAP or refractory periodontitis
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CEPHALOSPORINS
Are not used for treatment of dental disease.
CLINDAMYCIN
Effective against anaerobic bacteria with strong affinity
for osseous tissue.
For penicillin allergic patients.
Efficacy to periodontitis refractory to tetracycline
therapy.
DOSES: 150mg (qid) for 10 days.
300mg(bid) for 8 days.
Associated with pseudomembranous colitis.
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CIPROFLOXACIN
A quinolone active against gram negative rods (all
facultative, some anaerobic putative periodontal
pathogens).
Ciprofloxacin therapy may facilitate establishment of a
microflora associated with periodontal health.
ONLY antibiotic that all strains of A.a are susceptible.
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CIPROFLOXACIN
Side effects:
metallic taste,
inhibit the metabolism of theophylline and caffeine.
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MACROLIDS
Inhibit protien synthesis, bacteriostatic or bactericidal
depending on drug concentration.
Macrolids used in periodontal treatment include
erythromycin, spiramycin, and azithromycin.
DOSES: Therapeutic doses of 250mg/day for 5 days
after an initial loading dose of 500mg.
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MACROLIDS
DID YOU KNOW.
Erythromycin is not concentrated in GCF, spiramycin is
excreted in high concentration in saliva and it has
been proposed that azithromycin penetrates fibroblasts
and phagocytes in concentrations 100-200 times
greater than extacellular compartment!!!
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ANTIBIOTIC THERAPY
Bacteriostatic Bactericidal
Erythromycin Penicillin
Tetracycline Cephalosporin
Clindamycin Vancomycin
Metronidazole
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GUIDELINES FOR
ANTIBIOTICS IN
PERIODONTAL THERAPY
1. Clinical diagnosis and situation dictate the need for
ABC therapy.
2. Disease activity, measured by continuing attachment
loss, purulent exudates
3. Patient medical and dental status and current
medication.
4. Microbiological plaque sampling.
5. Identification of which antibiotics were most
effective
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Subgingival chlorhexidine .
Tetracycline containing fiber.
Subgingival doxycycline.
Subgingival minocycline.
Subgingival metronidazole.
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SUBGINGIVAL
CHLORHEXIDINE
A resorbable delivery system.
Biodegradable system that resorbs in 7-10 days.
Perio Chip is a small chip (4.0 5.0 0.35 mm).
TETRACYCLINE CONTAINING 28
FIBER (ACTISITE)
consists of a polymer ethylene vinyl acetate
containing 25% of saturated tetracycline HCl. It is
marketed in the length of 23 cms and 0.5 mm diameter
containing 2.7 mg of tetracycline HCl
It was well tolerated in oral tissues and concentrations
reach 1300g/ml
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SUBGINGIVAL
DOXYCYCLINE
A gel system using a syringe with 10% doxycycline
(Atridox).
SUBGINGIVAL
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MINOCYCLINE(ARESTIN).
SUBGINGIVAL
METRONIDAZOLE
A topical medication containing an oil based
metronidazole 25% dental gel.
Two 25% gel application at a 1-week interval have
been used.
Bleeding on probing was reduced by 88% of cases.
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CONCLUSIONS
Scaling and root planing are effective in reducing
pocket depths.
When systemic antibiotics are used as adjuncts to
scaling and root planing the evidence indicate that
some antibiotics provide additional improvement.
There are extensive reviews of the local delivery agents
available for periodontitis.
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Chlorhexidine (CHX)
chlorhexidine was first investigated by Schroeder in 1969
is available in three forms,
the - digluconate,
- acetate
- hydrochloride salts
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Mechanism of Action
I. Antibacterial activity: chlorhexidine is rapidly attracted
to the negatively charged bacterial cell surface, with
specific and strong adsorption to phosphate containing
compounds.
II. Antiplaque activity
i. It blocks the acidic groups on the salivary glycoproteins
thus, inhibit pellicle formation.
ii. It directly binds to the bacterial surface in sublethal
amounts and thus, prevents the adsorption of bacteria
onto tooth surface.
iii. It inhibits acid production in established plaque
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Adverse effects:
i. Staining: Brown discoloration of teeth, restoration
and dorsum of tongue. The various proposed
mechanism of chlorhexidine staining are:
Degradation of chlorhexidine molecule to release
parachloraniline
Precipitation of anionic dietary chromogens
Protein denaturation with metal sulfide formation
Catalysis of Maillard reactions
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Listerine
It is phenol related essential oils consisting of
thymol (0.064%), eucalyptol (0.092%), methanol
(0.042%), methyl salicylate (0.060%) in
hydrochloride solution and benzoic acid (0.15%).
The advantages of listerine are that there is no
taste alteration or staining as seen with
chlorhexidine usage.
It is less expensive and is easier to obtain than
chlorhexidine, as it is sold over the counter.
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Peroxide
is an antiseptic agent that is toxic to many bacteria
because of its strongly oxidizing properties.
The critical factor in peroxide activity is the fact that
H2O2 and other reduction products of O2 (superoxide
anions) can generate the more toxic hydroxyl radicals.
These reactive O2 species
disadvantage
it is toxic to the host, causing peroxidation
of lipids in cell membrane and certain
chromosomal changes.
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Triclosan
Advantages:
No staining
Can inhibit several important mediators of gingival
inflammation
It has dual effect both as an antibacterial and anti
inflammatory
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Povidone Iodine
consists of iodine plus a solubilizing agent, i.e.
polyvinylpyrrolidone (povidone)
is microbiocidal for G+ve and G-ve bacteria, fungi,
mycobacteria, viruses and protozoans.
Its bacterial activity is due to oxidation of amino,
thiol and hydroxyl groups
The substantivity of povidone iodine is around 60
minutes.
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Natural Products
Sanguinarine
The trade name of Sanguinarine prouct is Viadent.
It is antimicrobial agent effective against gram-
positive and gram-negative bacteria.
it seems to interfere with essential steps in the
synthesis of bacterial cell wall. It suppresses the
activity of several enzymes.
Propolis It is used as plaque inhibitory mouthwash
because of its antiseptic, antiinflammatory and
bacteriostatic property
AGE CHANGES IN
PERIODONTAL
TISSUES
AGE CHANGES IN
PERIODONTAL TISSUES
All tissues under go certain changes as result of aging
Manifestations
1.Reduction in vascularity
2.Reparative capacity
3.Atrophy (senile atrophy )
e.g. with aging recession of gingiva and alveolar
bone resorption occur
FIG. MEASUREMENT OF PROBING DEPTH. NOTE
THE GINGIVAL
RECESSION AT THE BUCCAL ASPECT OF TEETH 21
AND 22.
RADIO GRAPHICALLY
CONTI
Greater prevalence of periodontal disease as age
advances is seen
As result of aging increased arteriosclerotic changes
occur
The width of periodontal ligament is generally reduced
as result of continous deposition of cementum & bone
FURCUSSION
CONTI
Reduction in masticatory function may also contribute
to narrowing of ligament space with age
Osteoporosis , decreased vascularity & gradual
reduction in metabolic rate have been reported in
alveolar bone with increased aging ,despite significant
age changes the residual periosteal & end steal cells
of alveolar bone seem capable of responding to
fuctional forces as well as trauma.
CONTI.
Cementum formation is continuous throughout life
cellular cementum is deposited in apical third of roots
to componsate for attrition (occlusal ,proximal area).
The arch length is believed to be reduced by o.5 cm by
age of 40.
CONTI.
Gradual reduction in gingival keratinization cellularity of
connective tissues & O2 tension have been reported in
gingiva as result of aging .
The oral epithelium appears thinner with age in most
cases
The width of attached gingiva increase with age
Number of elastic fibers in periodontal ligament has been
shown to increase with age & also decreased vascularity.
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Chemotherapeutic Agents
Antiplaque Agents
Fluoride