INDIAN DENTAL ACADEMYLeader in Continuing Dental Education    www.indiandentalacademy.com
Index•   Introduction•   Drug•   Drug nomenclature•   Routes of drug administration•   History•   Classification•    Probl...
•   Guidelines for use of antibiotics•   Tetracyclines•   β-lactum antibiotics (Penicillin)•   Clindamycin•   Quinolones (...
IntroductionConsidering the common occurrence of the periodontitis and the  vast amount of periodontal research performed ...
However, with the advent of effective systemic antibiotics and  topical antiseptics, the formerly dismal prognosis of many...
DrugThe disease oriented definition of drug does not include  contraceptives or use of drugs for the improvement of health...
Drug NomenclatureThe drug generally has three categories of names:•   Chemical name: Describes the substance chemically.  ...
Routes of Drug AdministrationRoutes can be broadly divided into:  - Those for local action  - And those for systemic actio...
- Local Routes   - Topical       - Skin       - Mucous membranes              - Mouth & Pharynx              - Eyes, Ears ...
- Deeper tissues (using injection)               - Intra artricular injection               - Intrathecal injection       ...
- Parenteral     - Subcutaneous             - Dermojet             - Pocket implantation             - Sialiastic (non bio...
Antimicrobial drugs  These are drugs in this class are different from all others in  that they are designed to inhibit /ki...
AntisepticsThey are chemical antimicrobial agents that are applied  topically or subgingivally to mucous membranes, wounds...
HistoryThe term “antibiotic” means “against life” (from the Greek word  anti-against biosis-life).The history of chemother...
• Ehrlich’s phase of dyes and organometallic compounds  (1890-1935): with the discovery of microbes in the later half  of ...
• The Modern era of chemotherapy was ushered by Dogmagk  in 1935 by demonstrating the therapeutic effect of Prontosil, a  ...
• Fleming (1929) found that a diffusible substance is as  elaborated by Penicillium mould which could destroy  Staphylococ...
In the 1940s Waksman and his colleagues undertook a  systematic search of Actinomycetes as source of antibiotics  and disc...
www.indiandentalacademy.com
ClassificationAccording to Chemical structure• Sulfonamides and related drugs: Sulfadiazine and others,  Sulfones—Dapsone ...
• Macrolide antibiotics: Erythromycin, Roxithromycin,  Azithromycin etc.• Polypeptide antibiotics: Polymyxin-B, Bacitracin...
According to mechanism of action• Inhibit cell wall synthesis: Penicillins, Cephalosporins,  Cycloserine, Vancomycin, Baci...
Type of organisms against which primarily active• Antibacterial: Penicillins, Aminoglycosides, Erythromycin  etc.• Antifun...
Spectrum of activityNarrow spectrum                   Broad spectrum      Penicillin G                Tetracyclines      S...
Antibiotics are obtained from:• FungiPenicillin            Griseofulvin          Cephalosporin• BacteriaPolymyxin B       ...
PROBLEMS WITH THE USE OF ANTIMICROBIALS                       HYPERSENSITIVITYTOXICITY                                    ...
Problems with the use of antimicrobialToxicity(a) Local irritancy: This is experienced at the site of    administration. G...
• Amyloglycosides: 8th cranial nerve and kidney toxicity• Tetracyclines: Liver and kidney damage, antianabolic effect• Chl...
• Hypersensitivity reactionsPractically all AMA’s are capable of causing hypersensitivity   reactions. These are unpredict...
• Natural resistanceSome microbes have been resistant to certain AMAs. They lack  the metabolic process or the target site...
• MutationIt is a stable and heritable genetic change that occurs   spontaneously and randomly among microorganisms. It is...
• Gene transferFrom one organism to another organism by:  - Conjucation (Sexual contact; Commonly in gram -ve bacilli     ...
• Adaptive resistanceA kind of rapidly developing (over 1-2 hrs) and reversible  (within 16-24 hrs) resistance based on ph...
• Cross resistanceAcquisition of resistance to one AMA conferring resistance to  another AMA, which the organism has not b...
Prevention of drug resistance  • No indiscriminate and inadequate or unduly prolonged use    of AMA should be made.  • Pre...
• SuperinfectionThis appears to appearance of new infection as a result of  antimicrobial therapy.Ordinarily, the pathogen...
Superinfection are more common when host defense is  compromised as in:   • Corticosteroid therapy   • Leukemias and other...
Commonly used antibiotics in the management of periodontal disease• Tetracyclines       (Minocycline,    Doxycycline,  Tet...
Guidelines for the use of antibiotics in the               periodontal therapy• The clinical diagnosis and the situation d...
Clinical DiagnosisHealth         Chronic Periodontitis          Aggressive, Refrectory periodontitis                      ...
TetracyclinesThe first to be introduced was chlortetracycline in 1948  under the name aureomycin.Tetracyclines have been w...
• Structurally, tetracyclines consist of four  fused rings, hence the name tetracyclines.          www.indiandentalacademy...
• Tetracycline derivatives, primarily doxycycline and  minocycline, differ from the parent compound by minor  alterations ...
They are effective in treating various periodontal disease in part  because their concentration in the gingival crevice is...
Mechanism of action• They are primarily bacteriostatic; inhibit protein synthesis by  binding to 30s ribosomes in suscepti...
Administration• Oral capsule is the dosage form in which tetracyclines are  most commonly administered. The capsule should...
www.indiandentalacademy.com
Clinical use• Tetracyclines have been investigated as adjuncts in the  treatment localized aggressive periodontitis (LAP)....
Resistance to tetracyclines• Resistance to the tetracyclines is relatively common and is  mediated by a number of genetic ...
Systemic administration of tetracyclines• Clinical studies on localized aggressive (juvenile) periodontitis  found that 1 ...
Local delivery of tetracyclines• The concept that local delivery of an antibiotic into the  periodontal pocket achieves a ...
• Locally administered antibiotics, at concentrations much  greater than can be achieved systemically, aid in site-specifi...
Tetracycline-Containing Fibers (Actisite)• The first local delivery product available in the U.S., one which  has been ext...
Subgingival Delivery of Doxycycline (Atridox)• Atridox® (manufactured by Atrix Laboratories, Fort Collins,  CO; licensed f...
Subgingival Delivery System for Minocycline  (Dentamycin and PerioCline)• A subgingival delivery system of 2% (w/w)  minoc...
Collagenase inhibitors• It is now recognized that the tetracyclines are also potent  inhibitors of matrix metalloproteinas...
• A series of double-blind, placebo-controlled clinical trials has  demonstrated that subantimicrobial dose doxycycline (S...
www.indiandentalacademy.com
TETRACYCLINE• Tetracycline requires administration of 250 mg. qid. It is  inexpensive, but compliance may be reduced by ha...
Beta lactum antibiotics                (Penicillins)• It is the first antibiotic to be used clinically in 1941.• It was or...
• The penicillins are a broad class of antibiotics that inhibit  bacterial cell wall synthesis and directly result in the ...
Semisynthetic penicillinsThey are produced by chemically combining specific side  chains or by incorporating specific prec...
Classification• Acid resistant alternative to Penicillin G      Phenoxymethyl penicillin (Penicillin V)• Penicillinase res...
Amoxicillin• Amoxicillin, a semisynthetic penicillin, has excellent activity  against both gram-negative and gram positive...
• Amoxicillin may be useful in the management of patients  with aggressive periodontitis, both in the localized and  gener...
• Haffajee et al. tested the efficacy obtained with four  systemically administrated agents, Augmentin, tetracycine,  ibup...
Clindamycin• Clindamycin is bacteriostatic and inhibits bacterial protein  synthesis by binding to the 50S ribosomal subun...
• Unfortunately, a number of undesirable adverse effects have  been associated with the use of clindamycin. Due to its aci...
• If disease activity was detected and microbial sampling  indicated sensitivity to clindamycin, the patient received a  t...
• Clindamycin has shown efficacy in patients with periodontitis  refractory to tetracycline therapy. Walker and co-workers...
Quinolones (Ciprofloxacin)• These are entirely synthetic antimicrobials having a  quinolone structure that are active prim...
Ciprofioxacin is a quinolone active against gram-negative rods,  including all facultative and some anaerobic putative  pe...
Nausea, headache, and abdominal discomfort have been  associated with ciprofloxacin. Quinolones inhibit the  metabolism of...
MacrolidesMacrolide antibiotics contain a many membered lactone ring to  which one or more deoxy sugars are attached. They...
• Azithromycin (Zithromax) is a member of the azalide class of  macrolides. It is effective against anaerobes and gram-  n...
Nitroimidazole (Metronidazole)• Metronidazole is a 5-nitroimidazole compound developed in  France to treat protozoal infec...
• Upon entry into an anaerobic organism, metronidazole is  reduced at the 5-nitro position by electron transport proteins ...
Metronidazole has been used clinically to treat:  Gingivitis  Acute necrotizing ulcerative gingivitis  Chronic periodontit...
• A single dose of metronidazole (250 mg orally) appears in  serum and gingival fluid in sufficient quantities to inhibit ...
Side Effects• Metronidazole has an antabuse effect when alcohol is  ingested. The response is generally proportional to th...
• Metronidazole crosses the placenta barrier,entering the fetal  circulation system. It is also secreted in breast milk. B...
• Local delivery of MetranidazoleLocalized delivery of metronidazole to specific, diseased sites  would allow minimal amou...
• Elyzol is a 25% metronidazole dental gel consisting of  metronidazole benzoate in a mixture of mono- and  triglycerides....
Serial & combination antibiotic therapies• Because periodontal infections may contain a wide diversity  of bacteria, no si...
• Rams and Slots reviewed combination therapy using systemic  metronidazole along with amoxicillin, Augmentin, or  ciprofl...
• Tinnco and co-workers found metronidazole and amoxicillin  to be clinically effective in treating localized aggressive  ...
Other AntimicrobialsAntimicrobials other than antibiotics have been used with  varying success in the treatment of various...
• The main disadvantage of the local drug delivery is that  gingival crevice may dilute or completely wash the agent out  ...
Indications•   Reduce plaque and gingivitis•   Periodontal pocket•   Apthous ulcer•   Orthodontic patients•   Handicapped ...
Criteria for use of antimicrobials• Substantivity• Safety• Stability• Efficacy           www.indiandentalacademy.com
Ideal properties•   Bactericidal, bacteristatic•   Eliminate pathogenic bacteria•   Affect bacterial adhesion, growth or m...
Chlorhexidine• Chlorhexidine has often been employed as an adjunct to  mechanical debridement due to its broad-spectrum  a...
• A biodegradable chlorhexidine containing gelatin chip  (PerioChip) has received Food & Drug Administration  approval in ...
• Daneshmand et al. did not find any microbial benefit when  the chlorhexidine chip was used as an adjunct to SRP  compare...
Providone - Iodine• Povidone-iodine (PVP-iodine) is a bactericidal antiseptic  whose mechanism of action includes oxidatio...
• Greenstein, in a recent review of the effects of PVP-iodine,  found evidence indicating PVP-iodine irrigation, delivered...
Conclusion• At present, there is no single periodontal therapeutic regimen  that will provide a beneficial response for al...
References• Clinical Periodontology       Newman, Takei, Carranza.• Medical pharmacology       K. D. Tripathi• Periodontol...
Upcoming SlideShare
Loading in...5
×

Antimicrobials in periodontics /certified fixed orthodontic courses by Indian dental academy

1,985

Published on

Welcome to Indian Dental Academy
The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and offering a wide range of dental certified courses in different formats.


Indian dental academy has a unique training program & curriculum that provides students with exceptional clinical skills and enabling them to return to their office with high level confidence and start treating patients

State of the art comprehensive training-Faculty of world wide repute &Very affordable.

Published in: Education
1 Comment
15 Likes
Statistics
Notes
No Downloads
Views
Total Views
1,985
On Slideshare
0
From Embeds
0
Number of Embeds
1
Actions
Shares
0
Downloads
0
Comments
1
Likes
15
Embeds 0
No embeds

No notes for slide

Antimicrobials in periodontics /certified fixed orthodontic courses by Indian dental academy

  1. 1. INDIAN DENTAL ACADEMYLeader in Continuing Dental Education www.indiandentalacademy.com
  2. 2. Index• Introduction• Drug• Drug nomenclature• Routes of drug administration• History• Classification• Problems with the use of antimicrobials• Commonly used antibiotics in the management of periodontal diseases www.indiandentalacademy.com
  3. 3. • Guidelines for use of antibiotics• Tetracyclines• β-lactum antibiotics (Penicillin)• Clindamycin• Quinolones (ciprofloxacin)• Macrolides• Nitroiminadazole (metranidazole)• Serial and combination therapies• Other antimicrobials • Chlorexidine • Providone – Iodine• Conclusion• References www.indiandentalacademy.com
  4. 4. IntroductionConsidering the common occurrence of the periodontitis and the vast amount of periodontal research performed during the last three decades one would furnish most appropriate management of various types of periodontal disease would now be a matter of agreement among dentists.Approaches to the periodontal treatment ranges front the Surgical, Ressective versus Regenerative, Professional Emphasis versus Patient emphasis and Mechanical versus Chemical therapy. www.indiandentalacademy.com
  5. 5. However, with the advent of effective systemic antibiotics and topical antiseptics, the formerly dismal prognosis of many types of rapidly progressive periodontitis has been dramatically changed.New and more effective antimicrobial treatments as well as better implementations of the existing therapies have significantly improved the prognosis of periodontal disease and many oral infections. Currently, properly selected local antiseptics and systemic antibiotic therapies can provide periodontal treatment that is generally effective, low-risk and affordable. www.indiandentalacademy.com
  6. 6. DrugThe disease oriented definition of drug does not include contraceptives or use of drugs for the improvement of health. WHO (1966) has given a more comprehensive definition:“Drug is any substance or product that is used or intended to be used to modify or explore physiological systems or pathological states for the benefit of the recipient.” www.indiandentalacademy.com
  7. 7. Drug NomenclatureThe drug generally has three categories of names:• Chemical name: Describes the substance chemically. E.g.- 1(Isopropylamino)-3-(1-napthyloxy) propane-2-ol (Propanolol).• Non-proprietary name: It is the name accepted by the competent scientific body such as the United States Adopted Name (USAN) Council. E.g.- Pethidine.• Proprietary (Brand) name: It is the name assigned by the manufacturers and is his property or trademark. One drug may have multiple proprietary names. E.g.- ALTOL, ATEN, LONOL for Atenolol. www.indiandentalacademy.com
  8. 8. Routes of Drug AdministrationRoutes can be broadly divided into: - Those for local action - And those for systemic action www.indiandentalacademy.com
  9. 9. - Local Routes - Topical - Skin - Mucous membranes - Mouth & Pharynx - Eyes, Ears & Nose - GI tract - Bronchi & Lungs - Urethra - Vagina - Anal canal www.indiandentalacademy.com
  10. 10. - Deeper tissues (using injection) - Intra artricular injection - Intrathecal injection - Retrobulbar injection - Arterial supply- Systemic routes - Oral - Sublingual or Buccal - Rectal - Cutaneous - Inhalational - Nasal www.indiandentalacademy.com
  11. 11. - Parenteral - Subcutaneous - Dermojet - Pocket implantation - Sialiastic (non biodegradable or biodegradable) - Intramuscular (I.M.) - Intravenous (I.V.) - Intradermal www.indiandentalacademy.com
  12. 12. Antimicrobial drugs These are drugs in this class are different from all others in that they are designed to inhibit /kill the infecting organism and to have no/minimal effect on the recipient.Antibiotics These are the substances produced by microorganisms, which suppress the growth or kill other microorganisms but are produced by the microbes but are needed in high concentration (ethanol, lactic acid, H2O2).Chemotherapeutic agents It is a general term that refers to the ability of an active chemical substance to provide therapeutic clinical benefits. www.indiandentalacademy.com
  13. 13. AntisepticsThey are chemical antimicrobial agents that are applied topically or subgingivally to mucous membranes, wounds, or intact dermal surfaces to destroy microorganisms and inhibit their reproduction or metabolism.DisinfectantsA subcategory of antiseptics, are antimicrobial agents that are generally applied to inanimate surfaces to destroy microorganisms. www.indiandentalacademy.com
  14. 14. HistoryThe term “antibiotic” means “against life” (from the Greek word anti-against biosis-life).The history of chemotherapy may be divided into 3 phases.• The period of empirical use: of ‘mouldy curd’ by Chinese on boils, chaulmoogra oil by Hindus in leprosy, chenopodium by Azetecs for intestinal worms, mercury by Paracelsus (16 th century) for syphilis, cinchona bark (17th century) for fevers. www.indiandentalacademy.com
  15. 15. • Ehrlich’s phase of dyes and organometallic compounds (1890-1935): with the discovery of microbes in the later half of the 19th century and that they are the cause of many diseases: Ehrlich toyed with the idea that if certain dyes could selectively stain microbes they could also be toxic to these organisms, and tried methyelene blue, trypan red etc.• He developed the arsenicals-atoxyl for sleeping sickness, arsphenamine in 1906 and nonarsphenamine in 1909 for syphilis. He coined the term ‘chemotherapy’ because he used drug of known chemical structure and showed that selective attenuation of infecting parasite was a practical proposition. www.indiandentalacademy.com
  16. 16. • The Modern era of chemotherapy was ushered by Dogmagk in 1935 by demonstrating the therapeutic effect of Prontosil, a sulfonamide dye, in pvogenic infection. It is as soon realized that the active moiety is as paraamino benzene sulfonamide, and the dye part was not essential. Sulfapiridine (M & B 693) was the first sulfonamide to be marketed in 1938.• The phenomenon of antibiosis was demonstrated by Pasteur in 1877: growth of anthrax bacilli in urine was inhibited by airborne bacteria. www.indiandentalacademy.com
  17. 17. • Fleming (1929) found that a diffusible substance is as elaborated by Penicillium mould which could destroy Staphylococcus on the culture plate. He named this substance penicillin but could not purify it.• Chain and Flores followed up this observation in 1939 is which culminated in the clinical use of penicillin in 1941. Because of the great potential of this discovery in treating war is wounds, commercial manufacture of penicillin soon started. www.indiandentalacademy.com
  18. 18. In the 1940s Waksman and his colleagues undertook a systematic search of Actinomycetes as source of antibiotics and discovered streptomycin in 1944. This group of soil microbes proved to be a treasure-house of antibiotics and soon tetracyclines, chloramphenicol, erythromycin and many others followed. All three groups of scientists Domagk, Fleming-Chain-Florey and Waksman received Nobel Prize for their discoveries. www.indiandentalacademy.com
  19. 19. www.indiandentalacademy.com
  20. 20. ClassificationAccording to Chemical structure• Sulfonamides and related drugs: Sulfadiazine and others, Sulfones—Dapsone (DDS), Paraaminosalicylic acid (PAS).• Diaminopyrimidines: Trimethoprim, Pyrimethamine.• Quinolones: Nalidixic acid, Norfloxacin, Ciprofloxacin etc.• β-Lactam antibiotics: Penicillins, Cephalosporins, Monobactams, Carbapenems.• Tetracyclines: Oxytetracycline, Doxycycline etc.• Nitrobenzene derivative: Chioramphenicol• Amino glycosides: Streptomycin, Gentamicin, Neomycin etc. www.indiandentalacademy.com
  21. 21. • Macrolide antibiotics: Erythromycin, Roxithromycin, Azithromycin etc.• Polypeptide antibiotics: Polymyxin-B, Bacitracin, Tyrothricin.• Glycopeptides: Vancomycin, Teicoplanin• Oxazolidinone: Linezolid.• Nitrofuran derivatives: Nitrofurantoin, Furazolidone.• Nitroimidazoles: Metronidazole, Tinidazole.• Nicotinic acid derivatives: Isoniazid, Pyrazinamide, Ethionamide.• Polyene antibiotics: Nysricin-B, Hamycin.• Azole derivatives: Miconazole, Clotrimazole, Ketoconazole, Fluconazole.• Others: Rifampin, Lincomycin, Clindamycin, Spectinomycin, Sod. fusidate, Cycloserine, Viomycin, Ethambutol, Thiacetazone, Clofazimine, Griseofulvin. www.indiandentalacademy.com
  22. 22. According to mechanism of action• Inhibit cell wall synthesis: Penicillins, Cephalosporins, Cycloserine, Vancomycin, Bacitracin.• Cause leakage from cell membranes: Polypeptides—Polymyxins, Colistin, Bacitracin. Polyenes—Amphotericin B, Nystatin, Hamycin.• Inhibit protein synthesis: Tetracyclines, Chioramphenicol, Erythromycin, Clindainycin, Linezolid.• Cause misreading of m-RNA code and affect permeability: Aminoglycosides—Streptomycin, Gentamicin etc.• Inhibit DNA gyrase: Fluoroquinolones— Ciprofloxacin.• Interfere with DNA function: Rifampin, Metronidazole.• Interfere with DNA synthesis: Acyclovir, Zidovudine.• Interfere with intermediary metabolism:• Sulfonamides, Sulfones, PAS, Trimethoprim, Pyrimethamine, www.indiandentalacademy.com Ethambutol.
  23. 23. Type of organisms against which primarily active• Antibacterial: Penicillins, Aminoglycosides, Erythromycin etc.• Antifungal: Griseofulvin, Ketoconazole etc.• Antiviral: Idoxuridine, Acyclovir, Amantadine, Zidovudine etc.• Antiprotozoal: Chloroquine, Pyrimethamine, Metronidazole, Diloxanide etc.• Antielmintic: Mebendazole, Pyrantel, Nicolsamide, Diethyl carbamazine etc. www.indiandentalacademy.com
  24. 24. Spectrum of activityNarrow spectrum Broad spectrum Penicillin G Tetracyclines Streptomycin Chloramphenicol ErythromycinType of actionPrimarily bacteriostatic Primarily bactericidalSulfonamides PenicillinsEthambutol AminoglycosidesChloramphenicol RifampinTetracyclines CotrimoxazoleErythromycin Cephalosporins Vancomycin Ciprofloxacin www.indiandentalacademy.com
  25. 25. Antibiotics are obtained from:• FungiPenicillin Griseofulvin Cephalosporin• BacteriaPolymyxin B Tyrothxicin BacitracinColistin Aztreonam• ActinomycetesAminoglycosides Tetracyclines PolyenesChloramphenicol Macrolides www.indiandentalacademy.com
  26. 26. PROBLEMS WITH THE USE OF ANTIMICROBIALS HYPERSENSITIVITYTOXICITY DRUG REACTIONS RESISTANCE LOCAL SYSTEMICIRRITANCY TOXICITY NATURAL ACQUIRED ADAPTIVE CROSS MUTATION GENE TRANSFER SINGLE STEP MULTI STEP CONJUCATION TRANSDUCTION TRANSFORMATION www.indiandentalacademy.com
  27. 27. Problems with the use of antimicrobialToxicity(a) Local irritancy: This is experienced at the site of administration. Gastric irritation, pain and abscess formation at the site of injection, thromboflebitis of the injected vein are the complication.(b) Systemic toxicity: Practically all AMA’s produce dose related and systemic toxicities. Some have high therapeutic index-doses over nearly 100 fold range may be given without apparent damage to the host cells. www.indiandentalacademy.com
  28. 28. • Amyloglycosides: 8th cranial nerve and kidney toxicity• Tetracyclines: Liver and kidney damage, antianabolic effect• Chloramphemicol: Bone marrow depressionStill others have low therapeutic index (where no alternative is available)• Polymyxin B: Neurological and renal toxicity• Vancomycin: Hearing loss, kidney damage• Amphotericin B: Kidney, bone marrow and neurological toxicity. www.indiandentalacademy.com
  29. 29. • Hypersensitivity reactionsPractically all AMA’s are capable of causing hypersensitivity reactions. These are unpredictable and unrelated to dose. The whole range of reactions range from rashes to anaphylactic reactions.• Drug resistanceIt refers to unresponsiveness of a microorganism to an AMA and is akin to the phenomenon of tolerance seen in higher organisms. - Natural resistance (e.g. gram –ve bacilli) - Acquired resistance (e.g. staphylococci, coliform due to mutation & gene transfer) www.indiandentalacademy.com
  30. 30. • Natural resistanceSome microbes have been resistant to certain AMAs. They lack the metabolic process or the target sites which is affected by the particular drug. This is generally a group of species characteristics e.g. Gram -ve Bacilli are normally unaffected by Penicillin G.• Acquired resistanceIt is due to the development of resistance by an organism (which was sensitive) before due to use of an AMA over a period of time.The resistance is developed by two mechanisms: - Mutation - Gene transfer www.indiandentalacademy.com
  31. 31. • MutationIt is a stable and heritable genetic change that occurs spontaneously and randomly among microorganisms. It is not induced by the antimicrobial agents.Mutation and resistance may be: - Single step (High degree resistance; emerge rapidly) - Multistep (No. of gene modification involved; sensitivity decreases gradually in a stepwise manner) www.indiandentalacademy.com
  32. 32. • Gene transferFrom one organism to another organism by: - Conjucation (Sexual contact; Commonly in gram -ve bacilli of the same or another species; the gene carrying the ‘resistance’ or ‘R’ factor is transferred only if another ‘resistance transfer factor’ is also present.) - Transduction (Transfer of gene carrying resistance through the agency of a bacteriophage) - Transformation (Resistant bacterium may release the resistance carrying DNA into the medium) www.indiandentalacademy.com
  33. 33. • Adaptive resistanceA kind of rapidly developing (over 1-2 hrs) and reversible (within 16-24 hrs) resistance based on phenotypic attention in the bacteria, not involving genetic changes has been described for aminoglycoside antibiotic. This appears due to reversible down regulation of active transport of antibiotics into the gram negative bacteria.Similar adaptive resistance against some flouroquiolones has also been shown. www.indiandentalacademy.com
  34. 34. • Cross resistanceAcquisition of resistance to one AMA conferring resistance to another AMA, which the organism has not been exposed, called cross resistance.This is more commonly seen between chemically or mechanistically related drugs, e.g., resistance to any one sulfonamide means resistance to all others. www.indiandentalacademy.com
  35. 35. Prevention of drug resistance • No indiscriminate and inadequate or unduly prolonged use of AMA should be made. • Prefer rapidly acting and selective (narrow spectrum) AMAs whenever possible. • Use combination of AMAs whenever prolonged therapy is undertaken. www.indiandentalacademy.com
  36. 36. • SuperinfectionThis appears to appearance of new infection as a result of antimicrobial therapy.Ordinarily, the pathogens has to compete with the normal flora for the nutrients etc. to establish itself. Lack of competition may allow even a normally non-pathogenic component of the flora, which is not inhibited by the drug (e.g. candida), to predominate and invade.It is commonly associated with the use of broad spectrum antibiotics such as tetracyclines, chloramphenicol, ampicillin, newer cephalosporins especially when combination of these are employed. www.indiandentalacademy.com
  37. 37. Superinfection are more common when host defense is compromised as in: • Corticosteroid therapy • Leukemias and other malignancies, specially when treated with anticancer drugs. • AIDS • Agranulocytosis • DiabetesTo minimize superinfections: • Use specific (narrow spectrum) AMAs whenever possible. • Do not use AMAs to treat trivial, self limiting or untreatable (viral) infections. • Do not unnecessarily prolong antimicrobial therapy. www.indiandentalacademy.com
  38. 38. Commonly used antibiotics in the management of periodontal disease• Tetracyclines (Minocycline, Doxycycline, Tetracycline)• Penicillin (Amoxicillin, Augmentin)• Quinolone (Ciprofloxacin)• Nitroimidazole (Metronidazole)• Macrolides (Azithromycin)• Lincomycin derivatives (Clindamycin)• Other antibiotics www.indiandentalacademy.com
  39. 39. Guidelines for the use of antibiotics in the periodontal therapy• The clinical diagnosis and the situation dictates the need for the possible antibiotic therapy as an adjunct in controlling active periodontal disease.• Continuing disease activity, as measured by continuing attachment loss, purulent exudate and/or continuing periodontal pocket of ≥ 5mm that bleed on probing is an indication for microbial analysis and further periodontal therapy.• Based on the microbial composition of the plaque, the patient’s medical status and the current medications.• According on the microbiologic sampling www.indiandentalacademy.com
  40. 40. Clinical DiagnosisHealth Chronic Periodontitis Aggressive, Refrectory periodontitis or medically related periodontitis Periodontal therapy including: • Oral hygiene Microbial analysis • Root debridement • Supportive periodontal treatment and/or • Surgical access for root debridement or regenerative therapy • Antibiotics as indicated by microbial analysis Effective Ineffective www.indiandentalacademy.com SUPPORTIVE PERIODONTAL TREATMENT
  41. 41. TetracyclinesThe first to be introduced was chlortetracycline in 1948 under the name aureomycin.Tetracyclines have been widely used in the treatment of periodontal diseases. They have been frequently used in treating refractory periodontitis, including localized aggressive periodontitis.Tetracyclines have the ability to concentrate in the periodontal tissues and inhibit the growth of Actinobacillus actinomycetemcomitans. In addition they exert an anticollagenase effect that can inhibit tissue destruction and may aid bone regeneration. www.indiandentalacademy.com
  42. 42. • Structurally, tetracyclines consist of four fused rings, hence the name tetracyclines. www.indiandentalacademy.com
  43. 43. • Tetracycline derivatives, primarily doxycycline and minocycline, differ from the parent compound by minor alterations of chemical constituents attached to the basic ring structure.• These minor alterations in the molecular structure make both doxycycline and minocycline more lipophilic than the parent compound, resulting in better adsorption following systemic delivery and better penetration into the bacterial cell. Thus, lower and less frequent doses of doxycycline and minocycline can be given. For this reason and due to the widespread resistance to tetracycline- HCl, doxycycline and minocycline tend to be the tetracyclines most commonly used. www.indiandentalacademy.com
  44. 44. They are effective in treating various periodontal disease in part because their concentration in the gingival crevice is 2 to 10 times that in serum.In addition several studies have demonstrated that tetracyclines at low gingival crevicular fluid concentration (2 to 4 μg/ml) are very effective against various periodontal diseases. www.indiandentalacademy.com
  45. 45. Mechanism of action• They are primarily bacteriostatic; inhibit protein synthesis by binding to 30s ribosomes in susceptible microorganisms.• The sensitive organisms have an energy dependent active transport process which concentrates tetracycline intracellularly.• In gram-ve bacteria they diffuse through the porin channels as well. The more lipid soluble members enter by the passive diffusion also.• These two factors are responsible for selective toxicity of tetracycline for the microbes. www.indiandentalacademy.com
  46. 46. Administration• Oral capsule is the dosage form in which tetracyclines are most commonly administered. The capsule should be taken ½ hr before or 2 hr after food.• Tetracyclines are not recommended by I.M. route because it is painful and absorption from the injection site is poor. Slow I.V. injection may be given in severe cases, but is rarely required now.• A variety of topical preparations (ointment, cream etc.) are available, but should not be used, because there is high risk of sensitization. www.indiandentalacademy.com
  47. 47. www.indiandentalacademy.com
  48. 48. Clinical use• Tetracyclines have been investigated as adjuncts in the treatment localized aggressive periodontitis (LAP). Actinomycetemcomitans is a frequent causative microorganism in LAP and is tissue invasive. Therefore mechanical removal of calculus and plaque from root surfaces may not eliminate this bacterium from periodontal tissues.• Systemic tetracycline can eliminate tissue bacteria and has been shown to arrest bone loss and suppress Actinomycetemcomitans levels conjunction with scaling and root planning.• This combined form of therapy allows mechanical removal of root surface deposits and elimination of pathogenic bacteria from within the tissues. Increased post treatment bone levels have been noted using this method. www.indiandentalacademy.com
  49. 49. Resistance to tetracyclines• Resistance to the tetracyclines is relatively common and is mediated by a number of genetic determinants that may be located on plasmids or on the bacterial chromosome. Resistance may occur due to the coding of an efflux pump that actively removes the drug from the bacterial cell so that sufficient drug concentration is never achieved within the cell.• Another mode of resistance is referred to as ribosome protection. With this mechanism, tetracycline antibiotics are not removed from the bacterial cell but are prevented from binding to the 30s ribosomal subunit. This mechanism generally conveys resistance equally to all tetracyclines. www.indiandentalacademy.com
  50. 50. Systemic administration of tetracyclines• Clinical studies on localized aggressive (juvenile) periodontitis found that 1 g ⁄day of tetracycline-HCl enhanced resolution of gingival inflammation and supported the gain of clinical attachment and alveolar bone. (Lindhe J, Polson AM et. al. , Slots J et. al.)• However, tetracycline and SRP did not suppress A. actinomycetemcomitans in all localized aggressive periodontitis patients. (Slots J, Rosling BJ)• Lindhe reported that renewed disease activity occurred in up to 25% of localized aggressive periodontitis patients treated with adjunctive tetracycline therapy despite a strict 3-month follow- up interval. Additional studies have demonstrated that both doxycycline and minocycline, like tetracycline, may significantly suppress A. actinomycetemcomitans but not totally eradicate the bacterium from all sites. www.indiandentalacademy.com
  51. 51. Local delivery of tetracyclines• The concept that local delivery of an antibiotic into the periodontal pocket achieves a greater, more potent concentration of drug than available with systemic delivery is very appealing.• The amount of drug delivered often creates sulcular medication concentrations exceeding the equivalent of 1 mg/ml (1,000 μg/ml). This level is considered bactericidal for the majority of bacteria that exhibit resistance to systemically delivered concentrations. www.indiandentalacademy.com
  52. 52. • Locally administered antibiotics, at concentrations much greater than can be achieved systemically, aid in site-specific elimination of residual bacteria. Tetracycline, doxycycline, and minocycline have been individually incorporated into local continuous delivery devices and made commercially available to the practitioner.• Both tetracycline, 12.7 mg tetracycline- HCl in an ethylene⁄vinyl acetate copolymer fiber (Actisite®), and doxycycline, 10% doxycycline hyclate in a gel delivery system (Atridox®), have been subjected to extensive testing.• Minocycline, the most lipophilic of the tetracyclines, has also been incorporated into a local delivery device consisting of minocycline-HCl microspheres (Arestin®). www.indiandentalacademy.com
  53. 53. Tetracycline-Containing Fibers (Actisite)• The first local delivery product available in the U.S., one which has been extensively studied, is an ethylene/vinyl acetate copolymer fiber, diameter 0.5 mm containing tetracycline, 12.7 mg/9 inches (Actisite tetracycline fiber; manufactured by Alza Corporation, Palo Alto, CA; distributed by Procter & Gamble Co., Cincinnati, OH).• When packed into a periodontal pocket, it is well tolerated by oral tissues, and for 10 days it sustains tetracycline concentrations exceeding 1300 g/ml well beyond the 32 to 64 μg/ml required to inhibit the growth of pathogens isolated from periodontal pockets. In contrast, crevicular fluid concentrations of only 4 to 8 μg/ml are reported after systemic tetracycline administration, 250mg four times daily tenwww.indiandentalacademy.comg) days. (total oral dose, 10
  54. 54. Subgingival Delivery of Doxycycline (Atridox)• Atridox® (manufactured by Atrix Laboratories, Fort Collins, CO; licensed for marketing by Block Drug, Inc., Jersey City NJ) is a gel system that incorporates the antibiotic doxycycline (10%) in a syringeable gel system. www.indiandentalacademy.com
  55. 55. Subgingival Delivery System for Minocycline (Dentamycin and PerioCline)• A subgingival delivery system of 2% (w/w) minocycline hydrochloride (Dentamycin, Cyanamid International, Lederle Division, Wayne, NJ; PerioCline, SunStar, Osaka, Japan) is available in many countries for use as an adjunct to subgingival debridement. This system is a syringeable gel suspension delivery formulation. www.indiandentalacademy.com
  56. 56. Collagenase inhibitors• It is now recognized that the tetracyclines are also potent inhibitors of matrix metalloproteinases, a family of enzymes that degrade extracellular matrix molecules such as collagen.• Pathologic elevated levels of matrix metalloproteinases result in the breakdown of the structural components of the periodontium. Doxycycline, in particular, downregulates matrix metalloproteinase activity in inflamed periodontal tissues by a mechanism that is unrelated to its antimicrobial properties. www.indiandentalacademy.com
  57. 57. • A series of double-blind, placebo-controlled clinical trials has demonstrated that subantimicrobial dose doxycycline (SDD), 20 mg bid (Periostat®), produces an improvement in clinical indices, without causing any detectable effect on the subgingival flora or an increase in antibiotic resistance. www.indiandentalacademy.com
  58. 58. www.indiandentalacademy.com
  59. 59. TETRACYCLINE• Tetracycline requires administration of 250 mg. qid. It is inexpensive, but compliance may be reduced by having to take four capsules per day.MINOCYCLINE• Minocycline can be given twice a day, thus facilitating compliance when compared with tetracycline. Although it is associated with less photo- and renal toxicity than tetracycline, it may cause reversible vertigo. Minocycline administered in a dosage of 200mg per day for 1 week results in a reduction in total bacterial counts.DOXYCYCLINE• The recommended dosage when used as an antimicrobial agent is 100 mg twice daily the first day, then 100 mg once daily. To reduce gastrointestinal upset, 50 mg can be taken twice daily. When used in a subantimicrobial dose to inhibit collagenase, it is recommended in a 20 mg dose twice daily. www.indiandentalacademy.com
  60. 60. Beta lactum antibiotics (Penicillins)• It is the first antibiotic to be used clinically in 1941.• It was originally obtained from fungus Penicillium notatum, but the present source is a highly yielding mutant of P. chrysogenum.• They are natural and semisynthetic derivatives of broth cultures of Penicillium mould.• They inhibit bacterial cell wall production and are therefore bactericidal. www.indiandentalacademy.com
  61. 61. • The penicillins are a broad class of antibiotics that inhibit bacterial cell wall synthesis and directly result in the death of the cell. All penicillins consist of a β-lactam ring, a thiazolidine ring, and an acyl side chain.• Substitutions on the acyl side chain have yielded a wide variety of penicillin compounds with vastly different properties. These include improved stability to gastric acid, improved absorption and higher serum concentrations, and activity against gram-negative as well as gram- positive bacteria. www.indiandentalacademy.com
  62. 62. Semisynthetic penicillinsThey are produced by chemically combining specific side chains or by incorporating specific precursors in the mould cultures.The main aim of producing these is to overcome:• Poor oral efficacy• Susceptibility to penicillinase• Narrow spectrum of activity• Hypersensitivity www.indiandentalacademy.com
  63. 63. Classification• Acid resistant alternative to Penicillin G Phenoxymethyl penicillin (Penicillin V)• Penicillinase resistant penicillins Methicillin, Oxacillin, Cloxacillin• Extended spectrum penicillins • Aminopenicillins Ampicillin, Bacampicillin, Amoxacillin • Carboxypenicillins Carbenicillin • Uredopenicillins Piperacillin • β-lactamase inhibitors Clavulanic acid www.indiandentalacademy.com
  64. 64. Amoxicillin• Amoxicillin, a semisynthetic penicillin, has excellent activity against both gram-negative and gram positive bacteria, is absorbed well following oral administration, and penetrates into the gingival crevicular fluid.• Unfortunately, amoxicillin is also highly susceptible to bacterial β-lactamases.• Augmentin, introduced a little over a decade ago, combines the antibiotic amoxicillin with a β-lactamase inhibitor, clavulanic acid. Many β-lactamase enzymes of oral origin have a greater affinity for clavulanic acid than for amoxicillin, are preferentially bound to the clavulanate moiety, and are competitively removed from hydrolyzing the β-lactam ring in amoxicillin. www.indiandentalacademy.com
  65. 65. • Amoxicillin may be useful in the management of patients with aggressive periodontitis, both in the localized and generalized forms. Recommended dosage is 500 mg TID for 8 days. www.indiandentalacademy.com
  66. 66. • Haffajee et al. tested the efficacy obtained with four systemically administrated agents, Augmentin, tetracycine, ibuprofen, or placebo, in conjunction with Widman flap procedure. Subjects that received either Augmentin or tetacycline demonstrated significantly more attachment gain than did the other two groups.• In contrast, Winkel et al. in double-blind, placebocontrolled study with 21 patients with a diagnosis of generalized adult periodontitis found that, in comparison with placebo, Augmentin provided no additional clinical or microbiological benefits. www.indiandentalacademy.com
  67. 67. Clindamycin• Clindamycin is bacteriostatic and inhibits bacterial protein synthesis by binding to the 50S ribosomal subunit. The drug is active against most gram- positive bacteria, including both facultative and anaerobic species. It is particularly active against gram-negative anaerobes and is very active against the gram-negative anaerobes associated with the periodontal flora. www.indiandentalacademy.com
  68. 68. • Unfortunately, a number of undesirable adverse effects have been associated with the use of clindamycin. Due to its acidic nature and to its effect on the gram-negative intestinal bacteria, adverse effects such as diarrhea, abdominal cramping, esophagitis, and stomach irritation are relatively common. There have been numerous reports of pseudomembranous colitis linked to the use of clindamycin.• Gordon et al. selected 13 subjects refractory to previous periodontal therapy consisting of mechanical debridement, periodontal surgery, and the adjunctive use of both tetracycline and a β-lactam antibiotic. www.indiandentalacademy.com
  69. 69. • If disease activity was detected and microbial sampling indicated sensitivity to clindamycin, the patient received a thorough scaling and was placed on clindamycin-HCL for 7 days. Of the 13 patients entered, 11 experienced no further loss of clinical attachment. The proportion of active sites decreased from an average of 10.7% to 0.5% per patient per year. At 24 months, a mean gain of 1.5 mm of clinical attachment was present.• Two additional studies, by Ohta et al. and Magnusson et al., demonstrated similar findings, namely gain in clinical attachment level and reduction in gram-negative anaerobes following the adjunctive use of clindamycin. www.indiandentalacademy.com
  70. 70. • Clindamycin has shown efficacy in patients with periodontitis refractory to tetracycline therapy. Walker and co-workers have shown aid in stabilizing refractory periodontitis. Dosage used in their studies was 150 mg qid for 10 days. Jorgensen and Slots have recommended a regimen of 300 mg twice daily 8 days. www.indiandentalacademy.com
  71. 71. Quinolones (Ciprofloxacin)• These are entirely synthetic antimicrobials having a quinolone structure that are active primarily against gram negative bacteria, through newer flourinated compounds also inhibit gram positive ones.• A breakthrough was achieved in the early 1980s by flourination of the quinolone structure at position 6 and introduction of a piperazine substitution at position 7 resulting in derivatives called fluoroquinolones with a higher potency, expanded spectrum, slow development of resistance, better tissue penetration and good tolerability. www.indiandentalacademy.com
  72. 72. Ciprofioxacin is a quinolone active against gram-negative rods, including all facultative and some anaerobic putative periodontal pathogens.The MIC of ciprofloxacin against gram negative bacteria is <0.1 μg/ml, while gram positive bacteria are inhibited at relatively higher concentrations.Ciprofloxacin therapy may facilitate the establishment of microflora associated with periodontal health. At present, ciprofloxacin is the only antibiotic in periodontal therapy to which all strains of A. actinomycetemcomitans are susceptible. It is also used in combination with metronidazole. www.indiandentalacademy.com
  73. 73. Nausea, headache, and abdominal discomfort have been associated with ciprofloxacin. Quinolones inhibit the metabolism of theophvlline and caffeine and concurrent administration can produce toxicity. They have also been reported to enhance the effect of warfarin and other anticoagulants. www.indiandentalacademy.com
  74. 74. MacrolidesMacrolide antibiotics contain a many membered lactone ring to which one or more deoxy sugars are attached. They inhibit protein synthesis by binding to the 50s ribosomal subunits of sensitive microorganisms. They can be bacteriostatic or bactericidal, depending on the concentration of the drug and the nature of the microorganism. www.indiandentalacademy.com
  75. 75. • Azithromycin (Zithromax) is a member of the azalide class of macrolides. It is effective against anaerobes and gram- negative bacilli. After an oral dosage of 500mg once daily for three consecutive days, significant levels of azithromycin were detected in most tissues for 7 to 8 days.• It has been proposed that azithromycin penetrates fibroblasts and phagocytes in concentration 100 to 200 times greater than that of extracellular compartment. The azithromycin if actively transported to the sites of inflammation by phagocytes and then released directly into the site of inflammation as the phagocytes rupture during phagosytosis.• Therapeutic use requires single dose of 250mg per day for 5 days after an initial loading dose of 500mg. www.indiandentalacademy.com
  76. 76. Nitroimidazole (Metronidazole)• Metronidazole is a 5-nitroimidazole compound developed in France to treat protozoal infections. It is bactericidal to anaerobic organisms and believed to disrupt bacterial DNA synthesis in conditions where low reduction potential is present. www.indiandentalacademy.com
  77. 77. • Upon entry into an anaerobic organism, metronidazole is reduced at the 5-nitro position by electron transport proteins that are part of anaerobic metabolic energy-yielding pathways. Alteration of the metronidazole molecule creates a continuous concentration gradient favoring diffusion of additional metronidazole into the cell. Reduction of the parent compound yields many short-lived cytotoxic free radicals. These free radicals react with macromolecules, particularly DNA, resulting in cell death. www.indiandentalacademy.com
  78. 78. Metronidazole has been used clinically to treat: Gingivitis Acute necrotizing ulcerative gingivitis Chronic periodontitis Aggressive periodontitisIt has been used as monotherapy and also in combination with scaling and root planning and other antibiotics. www.indiandentalacademy.com
  79. 79. • A single dose of metronidazole (250 mg orally) appears in serum and gingival fluid in sufficient quantities to inhibit a wide range of suspected periodontal pathogens.• Administered systemically (750 to 1000 mg/day for 2 weeks), this drug reduces the growth of anaerobic flora.• The most commonly prescribed regiment is 250 mg tid for 7 days.• Loesche and co-workers found that 250 mg of metranidazole given three times daily for 1 week was of benefit to patients with diagnosed anaerobic periodontal infection. www.indiandentalacademy.com
  80. 80. Side Effects• Metronidazole has an antabuse effect when alcohol is ingested. The response is generally proportional to the amount ingested and can result in severe cramps, nausea, and vomiting.• Products containing alcohol should be avoided during therapy and for at least 1 day after therapy is discontinued.• It also inhibits warfarin metabolism. It should be avoided in patients on anticoagulant therapy as it increases prothrombin time. It should be avoided in patients taking lithium. www.indiandentalacademy.com
  81. 81. • Metronidazole crosses the placenta barrier,entering the fetal circulation system. It is also secreted in breast milk. Because of the association of metronidazole with tumorigenicity in some animals, the drug is contraindicated in pregnant women or nursing mothers. www.indiandentalacademy.com
  82. 82. • Local delivery of MetranidazoleLocalized delivery of metronidazole to specific, diseased sites would allow minimal amounts of drug to achieve high concentrations, alleviating many adverse reactions and unpleasant side-effects associated with systemic administration. www.indiandentalacademy.com
  83. 83. • Elyzol is a 25% metronidazole dental gel consisting of metronidazole benzoate in a mixture of mono- and triglycerides.• The formulation is delivered as a liquid to the periodontal pocket using a syringe device and changes immediately to a gel upon contact with the gingival fluid.• Metronidazole benzoate gradually disintegrates into metronidazole and delivers high concentrations of the drug to the periodontal pocket for approximately 24 h after placement. Normally, two applications of the dental gel administered 1 week apart are recommended. www.indiandentalacademy.com
  84. 84. Serial & combination antibiotic therapies• Because periodontal infections may contain a wide diversity of bacteria, no single antibiotic is effective against all putative pathogens. Indeed, differences exist in the microbial flora associated with the various periodontal disease syndromes.• These “mixed” infections can include a variety of aerobic, microaerophilic, and anaerobic bacteria, both gram negative and gram positive.• In these instances, it may be necessary to use more than one antibiotic, either serially or in combination. However, before combinations of antibiotics are used, the periodontal pathogen(s) being treated must be identified and antibiotic susceptibility testing performed. www.indiandentalacademy.com
  85. 85. • Rams and Slots reviewed combination therapy using systemic metronidazole along with amoxicillin, Augmentin, or ciprofloxacin. The metronidazole-amoxicillin and metronidazole-Augmentin combinations provided excellent elimination of many organisms in adult and localized aggressive periodontitis that had been treated unsuccessfully with tetracyclines and mechanical debridement. These drugs have an additive effect regarding suppression of A. actinomycetemcomitans. www.indiandentalacademy.com
  86. 86. • Tinnco and co-workers found metronidazole and amoxicillin to be clinically effective in treating localized aggressive periodontitis, although 50% of patients harbored A. actinomycetemcomitans one year later. Metronidazole- ciprofloxacin combination is effective against A. actinomycetemcomitans. Metronidazole targets obligate anaerobes, and ciprofloxacin targets facultative anaerobes. www.indiandentalacademy.com
  87. 87. Other AntimicrobialsAntimicrobials other than antibiotics have been used with varying success in the treatment of various periodontal disease syndromes.The route of antimicrobial administration, with the exception of systemic antibiotics, is almost always topical due to potential toxicity.Second, the anatomy of the diseased site, a periodontal pocket, is unique. www.indiandentalacademy.com
  88. 88. • The main disadvantage of the local drug delivery is that gingival crevice may dilute or completely wash the agent out of the periodontal pocket. (5-6mm pocket shows an outflow equal or greater to 20μl/h, this is equivalent to pocket volume turnover to 40 times per hour).• Due to the constant outflow of the gingival crevice fluid, the expected half-life of an antimicrobial in the periodontal pocket, unless it is incorporated in a continuous release device, is around 1 min. www.indiandentalacademy.com
  89. 89. Indications• Reduce plaque and gingivitis• Periodontal pocket• Apthous ulcer• Orthodontic patients• Handicapped patients• Adjunct to oral hygiene• Patients with crown and bridge• Post periodontal and oral surgery• Reduces aerosols• Patients with implants• Presence with hyperplasia and xerostomia www.indiandentalacademy.com
  90. 90. Criteria for use of antimicrobials• Substantivity• Safety• Stability• Efficacy www.indiandentalacademy.com
  91. 91. Ideal properties• Bactericidal, bacteristatic• Eliminate pathogenic bacteria• Affect bacterial adhesion, growth or metabolism• Prevent development of resistant bacteria• Reduce plaque and gingivitis• Safe to use• Inhibit calcification of plaque to calculus• Should not stain teeth/taste alteration• Easy to use• Inexpensive www.indiandentalacademy.com
  92. 92. Chlorhexidine• Chlorhexidine has often been employed as an adjunct to mechanical debridement due to its broad-spectrum antimicrobial activity, substantivity in the oral cavity and ease of use during oral irrigation or gel placement. www.indiandentalacademy.com
  93. 93. • A biodegradable chlorhexidine containing gelatin chip (PerioChip) has received Food & Drug Administration approval in the United States for use as an adjunct to SRP. The gelatin chip is placed directly into the periodontal pocket, releasing 2.5 mg of chlorhexidine over a period of 7– 10 days. Chlorhexidine levels, within the pocket, reach an average concentration equivalent to 125 μg of chlorhexidine per ml of gingival crevice fluid.• Daneshmand et al. did not find any microbial benefit when the chlorhexidine chip was used as an adjunct to SRP compared to SRP alone. www.indiandentalacademy.com
  94. 94. • Daneshmand et al. did not find any microbial benefit when the chlorhexidine chip was used as an adjunct to SRP compared to SRP alone.• In summary, there is no evidence that chlorhexidine applied to the periodontal pocket provides any significant advantage or additive effect to SRP alone. www.indiandentalacademy.com
  95. 95. Providone - Iodine• Povidone-iodine (PVP-iodine) is a bactericidal antiseptic whose mechanism of action includes oxidation of amino, thiol, and hydroxy moieties of amino acids and nucleotides.• PVP-iodine also interacts with the unsaturated fatty acids associated with bacterial cell walls and membranes. Because it adversely affects multiple bacterial sites, the effect of PVP- iodine occurs relatively quickly, decreasing the need for extended exposure time. www.indiandentalacademy.com
  96. 96. • Greenstein, in a recent review of the effects of PVP-iodine, found evidence indicating PVP-iodine irrigation, delivered to the periodontal pocket via ultrasonic scalers, achieved better results in deep pockets than water.• Rosling et al. tested the efficacy of PVP-iodine as an adjunct to conventional, nonsurgical periodontal therapy and retreatment in 223 advanced periodontitis subjects. One group received mechanical debridement via an ultrasonic device administering 0.1% PVP-iodine and the other group received mechanical debridement only. The group receiving PVP-iodine showed significantly lower mean probing pocket depth values and significantly more gain in clinical attachment. www.indiandentalacademy.com
  97. 97. Conclusion• At present, there is no single periodontal therapeutic regimen that will provide a beneficial response for all patients. It is patients very unlikely that there ever will be. Clinical trials are still needed to objectively evaluate adjunctive periodontal therapy. However, it is imperative that such trials be conducted with the appropriate patients. Little information is obtained by attempting to show a benefit for the use of adjunctive therapies in a patient group (e.g. non aggressive periodontitis) that responds very well to mechanical instrumentation alone. www.indiandentalacademy.com
  98. 98. References• Clinical Periodontology Newman, Takei, Carranza.• Medical pharmacology K. D. Tripathi• Periodontology 2000, Vol 36, 2004 www.indiandentalacademy.com

×