Antibiotic Adjuncts To Perio treatment

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Antibiotic Adjuncts To Perio treatment

  1. 1. ANTIBIOTIC ADJUNCTS TO PERIO DONTAL TREATMENT Aneesha abdu Final year bds GUIDED BY DR BINIRAJ K R PROF&HOD PERIODONTICS
  2. 2. <ul><li>Bacterial specificity </li></ul><ul><li>Should not produce resistant strains </li></ul><ul><li>Does not cause allergy or toxicity </li></ul><ul><li>Does not cause other side effects </li></ul><ul><li>Does not eliminate normal oral flora </li></ul><ul><li>Cost effective </li></ul><ul><li>Hence the ideal has not been found! </li></ul>Properties of an Ideal Antibiotic
  3. 3. PERIODONTITIS <ul><li>IS A COMPLEX DISEASE THAT INVOLVES THE LOSS OF ATTACHMENT AROUND TEETH RESULTING FROM ACTIONS OF MICROORGANISMS AND THE RESPONSE OF THE HOST TO THESE ORGANISMS. </li></ul>
  4. 4. PERIODONTITIS <ul><li>THE MOST EFFECTIVE TREATMENT CURRENTLY REQUIRES MECHANICAL ROOT PREPARATION IN THE PRESENCE OR ABSENCE OF SURGICAL REVISION OF THE PERIODONTIUM. </li></ul>
  5. 5. PERIODONTITIS <ul><li>TREATMENT CAN BE TIME CONSUMING, EXPENSIVE AND FRIGHTENING TO PATIENTS . </li></ul>
  6. 6. PERIODONTITIS <ul><li>THE SEARCH FOR A MAGIC BULLET IS A HIGH PRIORITY </li></ul>
  7. 7. PERIODONTAL PATHOGENS <ul><li>GRAM-NEGATIVE ANAEROBIC RODS </li></ul><ul><li>GRAM-POSITIVE FACULTATIVE AND ANAEROBIC COCCI AND RODS </li></ul><ul><li>GRAM-NEGATIVE FACULTATIVE RODS </li></ul>
  8. 8. PERIODONTITIS <ul><li>A.a. </li></ul><ul><li>P. gingivalis </li></ul><ul><li>T. denticola </li></ul><ul><li>B. forsythus </li></ul><ul><li>P. intermedia </li></ul><ul><li>E. nodatum </li></ul><ul><li>Spirochetes </li></ul>
  9. 9. PERIODONTAL PATHOGENESIS DEPEND ON… <ul><li>TOTAL BACTERIAL LOAD </li></ul><ul><li>BINDING OF THE DRUG TO TISSUES </li></ul><ul><li>BIOINACTIVATION OF THE DRUG BY NONTARGET ORGANISMS </li></ul><ul><li>BIOFILM PRESENCE AFFORDING THE PATHOGEN PROTECTION </li></ul><ul><li>DRUG RESISTANT PATHOGENS </li></ul><ul><li>IMPAIRED HOST RESISTANCE </li></ul><ul><li>RECOLONIZATION FROM SUPRAGINGIVAL SITES AFTER TERMINATION OF ANTIMICROBIAL THERAPY </li></ul>
  10. 10. ANTIBIOTICS <ul><li>PENICILLIN </li></ul><ul><li>MACROLIDES </li></ul><ul><li>TETRACYCLINE </li></ul><ul><li>CLINDAMYCIN </li></ul><ul><li>CIPROFLOXACIN </li></ul><ul><li>METRONIDAZOLE </li></ul>
  11. 11. SPECTRUM MACROLIDE CLINDA CEPHA AMPI/ AMOXY PEN G/ PEN V ORODENTAL INFECTIONS
  12. 13. Antibiotic Adjunctive Therapies <ul><li>Treatment of aggressive periodontal diseases, chronic periodontitis, refractory periodontitis </li></ul><ul><ul><li>Initial identification of pathogens </li></ul></ul><ul><ul><li>Appropriate antibiotic selection </li></ul></ul><ul><ul><li>Debridement should be carried out first </li></ul></ul><ul><li>Systemic antibiotics commonly prescribed: </li></ul><ul><ul><li>tetracyclines, metronidazole </li></ul></ul><ul><ul><li>amoxicillin, Augmentin, ampicillin </li></ul></ul><ul><ul><li>ciprofloxacin, clindamycin </li></ul></ul><ul><ul><li>Periostat ( doxycycline ) </li></ul></ul>
  13. 14. PENICILLINS <ul><li>INHIBIT BACTERIAL WALL SYNTHESIS </li></ul><ul><li>INDICATED IN ACUTE INFECTIONS FROM GRAM-POSITIVE BACTERIA </li></ul><ul><li>RESISTANT ORGANISMS </li></ul><ul><li>AMOXICILLIN MORE EFFECTIVE </li></ul><ul><li>CAN BE COMBINED WITH CLAVULINIC ACID WHICH PROTECTS AMOXICILLIN FROM DEGRADATION </li></ul><ul><li>NOT EFFECTIVE AGAINST Aa </li></ul>
  14. 15. MACROGLIDES <ul><li>CLINICALLY ADMINISTRATION DECREASED PLAQUE BUT PATIENTS DEVELOPED ABSCESSES DURING THE STUDY WHICH WORSENED THE CLINICAL PARAMETERS </li></ul><ul><li>NO SIGNIFICANT OR LASTING EFFECT WAS SEEN </li></ul>
  15. 16. MACROGLIDES <ul><li>ERYTHROMYCIN </li></ul><ul><li>CONTAINS A LACTONE RING TO WHICH SUGARS ARE ATTACHED WHICH BIND TO BACTERIAL RIBOSOMES AND DISRUPT PROTEIN SYNTHESIS </li></ul><ul><li>BACTERIOSTATIC </li></ul><ul><li>LIMITED ACTIVITY AGAINST PERIODONTAL PATHOGENS </li></ul><ul><li>LIMITED USE IN PERIODONTAL TREATMENT </li></ul>
  16. 17. TETRACYCLINES <ul><li>MOST COMMONLY PRESCRIBED ANTIMICROBIALS IN PERIODONTICS </li></ul><ul><li>INHIBIT PROTEIN SYNTHESIS BY BINDING TO BACTERIAL RIBOSOMAL UNITS </li></ul><ul><li>BROAD SPECTRUM </li></ul><ul><li>INCLUDES TETRACYCLINE, DOXYCYCLINE,AND MINOCYCLINE </li></ul><ul><li>MORE EFFECTIVE AGAINST GRAM POSITIVE </li></ul><ul><li>GOOD ACTIVITY AGAINST SPIROCHETES, ANAEROBIC AND FACULTATIVE BACTERIA </li></ul><ul><li>HIGH CONCENTRATIONS IN CREVICULAR FLUID </li></ul>
  17. 18. TETRACYCLINES <ul><li>CLINICAL USE IN ADULT PERIODONTITIS FOUND TETRACYCLINE TO BE NO DIFFERENT THAN PLACEBO </li></ul><ul><li>RELATIVE TO CHANGES IN PROBING DEPTHS, ATTACHMENT LEVELS AND PERCENTAGE OF SPIROCHETES. </li></ul><ul><li>HAVE BEEN WIDELY USED IN TREATMENT OF BOTH GENERALIZED AND LOCALIZED JUVENILE PERIODONTITIS </li></ul><ul><li>RELATIONSHIPS WERE FOUND BETWEEN THE DECREASE OF Aa IN THE POCKET AND AN INCREASE IN PROBING ATTACHMENT LEVELS. </li></ul>
  18. 19. TETRACYCLINES <ul><li>CLINICAL USE IN REFRACTORY PERIODONTITIS WAS BENEFICIAL BY SIGNIFICANTLY REDUCING SPIROCHETES, MOTILE RODS,PROBING DEPTHS AND SUPPURATION. </li></ul>
  19. 20. Tetracycline – Side Effects <ul><li>Intrinsic tooth staining </li></ul><ul><li>GI upset, abdominal pain </li></ul><ul><li>Diarrhea, vomiting </li></ul><ul><li>Fungal overgrowth </li></ul><ul><li>Resistant bacterial strains </li></ul><ul><li>Interferes with bactericidal activity of penicillin's & cephalosporins </li></ul>
  20. 21. DOXYCYCLINE <ul><li>A SIMILAR EFFICACY AND SPECTRUM OF ACTIVITY AS TETRACYCLINE </li></ul><ul><li>ELEVATED IN GINGIVAL CREVICULAR FLUID AT LEVELS COMPARABLE TO TETRACYCLINE </li></ul><ul><li>ABSORPTION OF DOXYCYCLINE IS LESS SENSITIVE TO THE PRESENCE OF FOOD </li></ul>
  21. 22. CLINDAMYCIN <ul><li>EFFECTIVE AGAINST GRAM-POSTITIVE AND MOST ANAEROBIC BACTERIA </li></ul><ul><li>INHIBITS BACTERIAL PROTEIN SYNTHESIS BY BINDING TO BACTERIAL RIBOSOMES </li></ul><ul><li>USE OF CLINDAMYCIN IN THE TREATMENT OF PERIODONTAL DISEASE HAS BEEN LIMITED BECAUSE OF POTENTIALLY SEVERE SIDE EFFECTS, SUCH AS ABDOMINAL DISCOMFORT, DIARRHEA, AND PSEUDOMEMBRANOUS COLITIS </li></ul>
  22. 23. CIPROFLOXACIN <ul><li>A BROAD-SPECTRUM ANTIMICROBIAL THAT INHIBITS BACTERIAL DNA SYNTHESIS THROUGH ITS BINDING TO DNA GYRASE, AN ENZYME RESPONSIBLE FOR THE UNWINDING AND SUPERCOILING OF DNA. </li></ul><ul><li>EFFECTIVE AGAINST GRAM-NEGATIVE BACTERIA, STAPHYLOCOCCI, AND PSEUDOMONAS AERUGINOSA. </li></ul><ul><li>MAY PROMOTE THE REPOPULATION OF THE PERIODONTIUM WITH BENEFICIAL MICROFLORA BY VIRTUE OF ITS SELECTIVITY. </li></ul>
  23. 24. CIPROFLOXACIN <ul><li>IT HAS A MINIMAL EFFECT ON STREPTOCOCCAL MICROBES </li></ul><ul><li>CIPROFLOXACIN THERAPY MAY FACILITATE THE REPOPULATION OF THE POCKET WITH MICROFLORA MORE ASSOCIATED WITH PERIODONTAL HEALTH </li></ul>
  24. 25. METRONIDAZOLE <ul><li>A BROAD- SPECTRUM ANTIMICROBIAL, DISPLAYING ACTIVITY AGAINST ANAEROBIC COCCI, GRAM-NEATIVE BACILLI, AND GRAM-POSITIVE BACILLI </li></ul><ul><li>PERMEABLE THROUGH THE BACTERIAL CELL WALL, THE DRUG BINDS DNA AND DISRUPTS THE HELICAL STRUCTURE. BREAKAGE OF THE DNA STRANDS FOLLOWS LEADING TO CELL DEATH. </li></ul><ul><li>LEVELS OF THE DRUG IN CREVICULAR FLUID CAN APPROACH TWICE THAT IN THE SERUM. </li></ul>
  25. 26. METRONIDAZOLE <ul><li>THE EFFECT OF THE METRONIDAZOLE WAS MAINTAINED FOR A TWO TO THREE YEAR RE-CALL PERIOD. IT CAN SIGNIFICANTLY REDUCE THE NEED FOR PERIODONTAL SURGERY COMPARED TO DEBRIDEMENT ALONE. </li></ul>
  26. 27. <ul><li>Mechanism of action: </li></ul><ul><ul><li>Bactericidal antimicrobial </li></ul></ul><ul><ul><li>Disrupts DNA synthesis leading to cell death </li></ul></ul><ul><ul><li>Selectively kills bacterial associated with periodontal disease </li></ul></ul><ul><ul><li>Susceptible bacteria include: </li></ul></ul><ul><ul><ul><li>Fusobacterium, Bacteroides </li></ul></ul></ul><ul><ul><ul><li>Peptostreptococcus </li></ul></ul></ul><ul><ul><ul><li>Treponema, Campylobacter </li></ul></ul></ul><ul><ul><ul><li>Veillonella </li></ul></ul></ul>
  27. 28. <ul><li>Clinical Considerations: </li></ul><ul><ul><li>GCF concentrations > blood serum levels </li></ul></ul><ul><ul><li>When combined with oral hygiene & debridement = beneficial effect on periodontitis </li></ul></ul><ul><ul><ul><li>Periodontal surgery may not be necessary </li></ul></ul></ul><ul><ul><li>Doxycycline may be substituted for metronidazole </li></ul></ul><ul><ul><ul><li>If client can’t abstain from alcohol </li></ul></ul></ul>
  28. 29. Before & AfterTreatment with Metronidazole <ul><li>Probing depth of 6 mm-before </li></ul><ul><li>Tissue shrinkage -after </li></ul>
  29. 30. Before & After Treatment with Metronidazole <ul><li>6 mm probing depths </li></ul><ul><li>Surgery has not been required </li></ul>
  30. 31. <ul><li>Some evidence of bone gain – client 2.5 years after initial debridement and use of metronidazole </li></ul>
  31. 32. <ul><li>Dosage: </li></ul><ul><ul><li>250 mg tid for 7-10 days </li></ul></ul><ul><ul><li>500 mg bid for 1-2 weeks </li></ul></ul><ul><li>Doxycycline </li></ul><ul><ul><li>100 mg per day or BID </li></ul></ul><ul><li>Metronidazole and amoxicillin or Augmentin </li></ul><ul><ul><li>250 mg (of each) TID for 7-10 days </li></ul></ul>
  32. 33. AntibioticProphylaxis (Prevention) <ul><li>Bacterial Endocarditis. </li></ul><ul><li>Prosthetic Joint Infections. </li></ul><ul><li>Immuno-Compromised Hosts. </li></ul><ul><li>Procedures and others. </li></ul>
  33. 34. SBE PROPHYLAXIS <ul><li>RECOMMENDED </li></ul><ul><li>Extractions, Periodontal procedures </li></ul><ul><li>Prophylactic cleaning </li></ul><ul><li>Implant placement, Re-implantation </li></ul><ul><li>Endodontic Instrumentation/Surgery beyond root apex, Placement or removal of orthodontic bands </li></ul><ul><li>Intraligamentary LA </li></ul>
  34. 35. SBE PROPHYLAXIS - 1 <ul><li>(1 hr before procedure) </li></ul><ul><li>STANDARD REGIMEN </li></ul><ul><li>Amoxicillin 2 g </li></ul><ul><li>PENICILLIN ALLERGY </li></ul><ul><li>Clindamycin 600 mg </li></ul><ul><li>Cephalexin/Cefadroxil 2 gm </li></ul><ul><li>Clarithromycin/Azithromycin 500 mg </li></ul>
  35. 36. SBE PROPHYLAXIS - 2 <ul><li>30 mins before procedure) </li></ul><ul><li>Failure to take P/O </li></ul><ul><li>Ampicillin 2 gm IM/IV </li></ul><ul><li>Penicillin allergy & Failure to take P/O </li></ul><ul><li>Clindamycin 600 mg IV </li></ul><ul><li>Cefazolin 1 gm IM/IV </li></ul>
  36. 37. LOCAL DELIVERY OF ANTIBIOTICS <ul><li>RECURRENT POCKETS IN THE PERIODONTAL MAINTENANCE PATIENT </li></ul><ul><li>THE FAILING IMPLANT </li></ul><ul><li>PERIODONTAL ABSCESSES </li></ul><ul><li>Work by suppressing destructive enzymes produced during inflammatory process or suppressing microbes </li></ul>
  37. 38. LOCAL DELIVERY OF ANTIBIOTICS <ul><li>TETRACYCLINE FIBER (ACTISITE) </li></ul><ul><li>DOXYCYCLINE POLYMER (ATRIDOX) </li></ul><ul><li>MINOCYCLINE OINTMENT (PERIOCLINE) </li></ul><ul><li>ARESTIN (MINOCYCLINE) </li></ul>
  38. 39. Advantages of Controlled Release Agents <ul><li>Client compliance not an issue </li></ul><ul><li>GCF concentration greater than serum levels </li></ul><ul><li>Delivery is localized – reduces systemic effects </li></ul><ul><li>Reduced side effects </li></ul>
  39. 40. Actisite  Periodontal Fiber <ul><li>Clinical use: </li></ul><ul><ul><li>Pockets measuring  5 mm, bleed on probing </li></ul></ul><ul><ul><li>Localized treatment for sites that have not responded to previous mechanical therapy </li></ul></ul><ul><li>How supplied: </li></ul><ul><ul><li>Cartons of 4 or 10 fibers </li></ul></ul><ul><ul><li>23 cm in length </li></ul></ul><ul><ul><li>12.7 mg tetracycline hydrochloride </li></ul></ul><ul><ul><li>Stored at room temperature </li></ul></ul>
  40. 41. Actisite  <ul><li>Application: </li></ul><ul><ul><li>Treat one quadrant or one side of mouth at a time </li></ul></ul><ul><ul><li>Client may request anaesthesia </li></ul></ul><ul><ul><li>Fiber inserted into pocket (circumferential or not) </li></ul></ul><ul><ul><ul><li>Takes about 10 minutes/tooth </li></ul></ul></ul><ul><ul><li>Some control of saliva </li></ul></ul><ul><ul><li>Should contact pocket base </li></ul></ul>
  41. 42. Actisite  <ul><li>Application: </li></ul><ul><ul><li>Sealed in place with adhesive </li></ul></ul><ul><ul><ul><li>Apply in thin even line along gingival margin </li></ul></ul></ul><ul><ul><ul><li>Surgical dressing not necessary but has been used </li></ul></ul></ul><ul><ul><li>Removed 7-10 days after placement </li></ul></ul><ul><ul><ul><li>Curette and/or cotton pliers </li></ul></ul></ul><ul><ul><ul><li>Fiber comes out in mass or pieces </li></ul></ul></ul><ul><ul><ul><li>Debride areas as necessary </li></ul></ul></ul><ul><ul><li>Tissue may appear red following removal </li></ul></ul>
  42. 43. Actisite  <ul><li>Adverse effects: </li></ul><ul><ul><li>Discomfort </li></ul></ul><ul><ul><li>Local erythema </li></ul></ul><ul><ul><li>Little systemic reaction </li></ul></ul><ul><ul><li>Used with caution in client with history of candidiasis </li></ul></ul><ul><ul><li>Application around 12+ teeth may result in oral candidiasis </li></ul></ul>
  43. 44. Actisite  <ul><li>Client instructions: </li></ul><ul><ul><li>Avoid brushing & flossing </li></ul></ul><ul><ul><li>Use antimicrobial rinse </li></ul></ul><ul><ul><ul><li>Use of CHX may have syngerstic effect </li></ul></ul></ul><ul><ul><li>Avoid hard or crunch foods, stick foods, chewing gum </li></ul></ul>
  44. 45. Actisite  <ul><li>Clinical Efficacy: </li></ul><ul><ul><li>Reduction in bleeding on probing and pocket depth </li></ul></ul><ul><ul><ul><li>More significant reductions in deeper pockets </li></ul></ul></ul><ul><ul><li>Reduction in periodontal pathogens </li></ul></ul><ul><ul><li>Effects of fiber on bone loss, tooth mobility or tooth loss not established </li></ul></ul>
  45. 46. Arestin  <ul><li>Clinical use: </li></ul><ul><ul><li>Periodontitis with pockets  5 mm </li></ul></ul><ul><li>How supplied: </li></ul><ul><ul><li>Box containing 2 trays each containing 12 cartridges </li></ul></ul><ul><ul><li>Cartridge contains 1 mg of minocycline (semisynthetic tetracycline derivative) microencapsulated in Poly dry powder </li></ul></ul><ul><ul><li>Cartridge inserted into a cartridge handle </li></ul></ul>
  46. 47. Arestin  <ul><li>Premeasured, premixed, no refrigeration necessary </li></ul>Preparing for Arestin
  47. 48. <ul><li>Mechanism of action: </li></ul><ul><ul><li>Broad spectrum </li></ul></ul><ul><ul><li>Bacteriostatic </li></ul></ul><ul><ul><li>GCF levels maintained at high levels for at least 14 days </li></ul></ul>
  48. 49. <ul><li>Application: </li></ul><ul><ul><li>Insert tip to base of periodontal pocket </li></ul></ul><ul><ul><li>Expel powder into pocket </li></ul></ul><ul><ul><li>Bioadhesive microspheres activate & adhere on contact with moisture </li></ul></ul><ul><ul><li>Cartridge contains enough Arestin for one periodontal pocket </li></ul></ul><ul><ul><li>Clinical trials: 30 sites treated in less than 10 minutes </li></ul></ul><ul><ul><li>Dressings or adhesives not required </li></ul></ul>
  49. 50. <ul><li>Adverse effects: </li></ul><ul><ul><li>Headache </li></ul></ul><ul><ul><li>Pain </li></ul></ul><ul><ul><li>Mouth ulceration </li></ul></ul><ul><ul><li>Slu syndrome </li></ul></ul><ul><ul><li>Stomatitis </li></ul></ul><ul><li>Client instructions: </li></ul><ul><ul><li>Do not eat hard or sticky foods for 1 week </li></ul></ul><ul><ul><li>Postpone brushing for 12 hours </li></ul></ul><ul><ul><li>Do not use interproximal cleaning aids for 10 days </li></ul></ul>
  50. 51. <ul><li>Clinical efficacy: </li></ul><ul><ul><li>27,000 sites treated, </li></ul></ul><ul><ul><li>Arestin with debridement demonstrated 27% greater pocket reduction in molars compared to debridement alone </li></ul></ul><ul><ul><ul><li>Mean reduction of 2 mm (pockets 7 mm +) </li></ul></ul></ul><ul><ul><li>Effective in furcations </li></ul></ul>
  51. 52. ATRIDOX <ul><li>A LIQUID BIODEGRADABLE DRUG DELIVERY SYSTEM THAT HARDENS IN THE PERIODONTAL POCKET AND GIVES A CONTROLLED RELEASE OF THE INCORPORATED AGENT </li></ul><ul><li>ADMINISTERED VIA SYRINGE </li></ul><ul><li>STUDIES IN PROGRESS UTILIZING THIS MATERIAL IN CONJUNCTION WITH ROOT PLANING AND SCALING </li></ul><ul><li>NOT FDA APPROVED </li></ul>
  52. 53. PERIOCLINE <ul><li>MANUFACTURED IN JAPAN </li></ul><ul><li>APPLIED INTO THE POCKET WITH A SYRINGE AND BLUNT CANNULA </li></ul><ul><li>REDUCTION IN PROBING POCKET DEPTH IN SITES TREATED WITH SCALING AND ROOT PLANING </li></ul>
  53. 54. PERIO CHIP <ul><li>CHLORHEXIDINE CHIP PLACED IN THE POCKET FOR LONG DRUG DELIVARY </li></ul>
  54. 55. BIBLIOGRAPHY <ul><li>TEXT BOOK OF PERIODONTOLOGY-CARRANZA </li></ul><ul><li>TEXT BOOK OF PERIODONTOLOGY-SHANTHIPRIYA REDDY </li></ul><ul><li>WWW.WIKIPEDIA.COM </li></ul><ul><li>WWW.CLINICS OF NORTH AMERICA.ORG </li></ul>
  55. 56. THANKS A LOT FOR YOUR ATTENTION......!!!

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