Antibiotic

1. Antibiotics In Periodontal
Therapy

2. Periodontitis
 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.

3. Periodontitis
 The most effective treatment requires
mechanical procedures;
 Scaling and Root planing;
 Aiming at the;
• Removal of Plague: prime causative factor
• Calculus; prime retentive factor
• Removal of diseased cementum and
smoothing of the root
In the presence or absence
of surgical procedures

4. Treatment of Periodontitis
 Mechanical Treatment can be;
 Time consuming,
 Expensive
 Uncomfortable for patients
 The search for a “magic bullet”
started a long time ago

5. Periodontal Bacteria
 Complex:
 Gram-negative
anaerobic rods
 Gram-positive
facultative and
anaerobic cocci and
rods
 Gram-negative
facultative rods

6. Putative Periodontal Pathogens
 A. actinomycetemcomitans
 P. gingivalis
 F. nucleatum
 T. denticola
 B. forsythus
 P. intermedia
 E. nodatum
 Etc……. about 40 species;
 Putative Periodontal Pathogens

7. Antibiotics in Periodontics
 Total bacterial load; mixed infection
 Bio-inactivation of the drug by non-target
organisms
 Drug resistant pathogens
 Impaired host resistance
 Re-colonization from supragingival sites after
termination of antimicrobial therapy
 Biofilm presence: protecting the pathogen
Factors affecting antibiotic therapy

8. Plaque as a Biofilm

9. Properties of an Ideal Antibiotic
1. Bacterial specificity
2. Should not produce resistant strains
3. Does not cause allergy or toxicity
4. Does not cause other side effects
5. Does not eliminate normal oral flora
6. Cost effective
 Hence the ideal has not been found!

10. Systemic Antibiotics: Advantages
 Delivery of drug to base of
pocket, furcation areas and
periodontal tissues via serum
 Bacterial reservoirs are treated
 Different antibiotics can be used

11. Antibiotic Adjunctive Therapies
 Indications; aggressive periodontitis, necrotizing
periodontal diseases, refractory periodontitis,
periodontal abscess (systemic symptoms) and
periodontitis associated with systemic immune
d e p l e t i n g d i s e a s e s
 Preconditions:
 Initial identification of pathogens
 Appropriate antibiotic selection
 Debridement should be carried out first
No antibiotics for
treatment of chronic periodontitis
and chronic gingivitis

12. Antibiotic Adjunctive Therapies
 Systemic antibiotics commonly prescribed:
 metronidazole
 amoxicillin, Augmentin,
 tetracyclines, doxycycline, minocycline
 ciprofloxacin,
 clindamycin

13. Systemic Use – Concerns
 Common side effects: Nausea, GI upset,
Diarrhea, Rash
 Dilution of drug before reaching GCF
 Patient noncompliance
 Biofilm effect
 Re-infection
 In broad spectrum antibiotics;
 Common oral manifestations:
• Black hairy tongue
• Oral candidiasis

14. Penicillins
 Inhibit bacterial wall synthesis
 Indicated in acute infections from gram-
positive bacteria
 Resistant organisms develop
 Amoxicillin more effective
 Can be combined with cluvanic acid which
protects amoxicillin from degradation;
Augmentin
 Not effective against
A. actinomycetemcomitans

15. Macroglides
 Erythromycin
 Contains a lactone ring to which sugars
are attached which bind to bacterial
ribosomes and disrupt protein synthesis
 Bacteriostatic
 Limited activity against periodontal
pathogens
 Limited use in periodontal treatment

16. Tetracyclines
 Tetracycline, doxycycline, and minocycline
 Clinical Use:
 Refractory periodontitis
 Localized aggressive periodontitis
 Growing trend to use combination therapies
– more effective
 Systemic & local delivery systems

17. Tetracyclines
 Inhibit protein synthesis by binding to bacterial
ribosomal units
 High concentrations in crevicular fluid
 Mechanism of action:
 Bacteriostatic, broad spectrum
 More effective against gram-positive bacteria
 However, A.a. highly sensitive
 Non-antibacterial properties:
• Inhibits production & secretion of
collagenase
• Inhibits bone resorption

18. Tetracycline
 Dosage:
 250 mg x 4 for 2 weeks

19. Tetracycline – Side Effects
 Intrinsic tooth staining
 GI upset, abdominal pain
 Diarrhea, vomiting
 Fungal overgrowth
 Resistant bacterial strains
 Interferes with bactericidal activity of
penicillin's & cephalosporins

20. Tetracyclines
 Clinical use together with Scaling and
RP in chronic periodontitis;
tetracycline was not different from
placebo relative to changes in probing
depths, attachment levels and percent
spirochetes.

21. Tetracyclines
 Have been widely used in treatment
of both generalized and localized
aggressive periodontitis

22. Tetracyclines
 Relationships were found between the
decrease of A. actinomycetemcomitans
in the pocket and an increase in probing
attachment levels.

23. Tetracyclines
 Use in refractory periodontitis was
beneficial by significantly reducing
spirochetes, motile rods;
 Parallel reduction in probing depths
and suppuration.

24. Doxycycline
 A similar efficacy and spectrum of activity
as tetracycline
 Elevated in gingival crevicular fluid at
levels comparable to tetracycline
 Absorption of doxycycline is less sensitive
to the presence of food

25. Clindamycin
 Effective against gram-postitive and most
anaerobic bacteria
 Inhibits bacterial protein synthesis by
binding to bacterial ribosomes
 Clindamycin; effective in controlling the
rate of attachment loss in refractory
periodontitis patients
 Limited use in the treatment of periodontal
disease because of potentially severe side
effects, such as;
 abdominal discomfort, diarrhea, and
pseudo-membranous colitis

26. Ciprofloxacin
 A broad-spectrum antimicrobial; inhibits
bacterial DNA synthesis through its binding to
DNA-gyrase, an enzyme responsible for the
unwinding and supercoiling of DNA.
 Effective against gram-negative bacteria,
staphylococci, and Pseudomonas aeruginosa.
 It has a minimal effect on streptococcal
microbes
 May promote the re-population of the
periodontium with beneficial microflora by virtue
of its selectivity.

27. Metronidazole
 A broad- spectrum antimicrobial agent,
displaying activity against anaerobic
cocci, gram-neative bacilli, and gram-
positive bacilli
 Permeable through the bacterial cell wall,
the drug binds DNA and disrupts its
helical structure; cell death.
 Levels of the drug in crevicular fluid can
approach twice that in the serum.

28. Metronidazole
 The effect of metronidazole was
maintained for 2 - 3 year re-call period.
 It can significantly reduce the need for
periodontal surgery compared to
debridement alone.

29. Metronidazole
 Showed complete elimination of A.
actinomycetemcomitans in nine
aggressive periodontitis subjects

30. Metronidazole
 Periodontal debridement and
Metronidazole has been successfully
used to treat refractory periodontitis
for up to two years

31. Metronidazole – Side Effects
 GI disturbances
 Headache
 Dry mouth
 Candida infections
 Metallic taste
 Nausea, diarrhea
 Stomatitis
 With alcohol; acute
nausea, headache,
vomiting

32. Metronidazole
 Clinical Considerations:
 GCF concentrations > blood serum levels
 When combined with oral hygiene & SC and RP;
beneficial effect on periodontitis
• Periodontal surgery may not be necessary
 Doxycycline may be substituted for metronidazole
• If patient can’t abstain from alcohol

33. Metronidazole
 Dosage:
 250 mg 1 x 4 for 14 days
 500 mg 1 x 2 for 14 days
 Combination therapy:
 Metronidazole (500 mg) and amoxicillin (250 mg)
or Augmentin (375mg) for 14 days

34. Metronidazole
Before & After Treatment
 Probing depth of 6 mm
 Tissue shrinkage &
recession

35. Before & After Treatment with
Metronidazole
 6 mm probing depths  Surgery has not been
required

36. Metronidazole
 Some evidence of bone gain; patient 2.5
years after initial debridement and use of
metronidazole

37. Local Delivery Of Antibiotics

38. Advantages of Local Delivery
(Controlled Release) Agents
 Patient compliance is better
 GCF concentration greater than serum
levels
 Delivery is localized – reduces systemic
effects; Reduced side effects

39. Local Delivery Of Antibiotics;
Indications
 localized lesions;
 Adjunctive therapy to debridement
 Patients with refractory periodontitis
• Recurrent or progressive pockets;
–Bleeding/non-bleeding pockets > 5 mm
 Periodontal abscesses
 Failing implants
 Where maintenance is preferred choice for
care;
• Surgical care is contraindicated

40. Local Delivery Of Antibiotics
 Tetracycline fiber (Actisite)
 Minocycline microsphere (Arestin)
 Doxycycline gel (Atridox)
 Minocycline ointment (Periocline)
 Chlorohexidine chip (PerioChip)
 Metronidazole gel (Elyzol)

41. Actisite Periodontal Fiber
 Clinical use:
 Pockets measuring  5 mm, bleed on probing
 Localized treatment for sites that have not
responded to previous mechanical therapy
 How supplied:
 Cartons of 4 or 10 fibers
 23 cm in length
 12.7 mg tetracycline hydrochloride
 Bactericidal concentration: > 150 times
that achieved by systemic tetracycline
 Stored at room temperature

42. Actisite
 Application:
 Treat one quadrant or one side of mouth at a
time
 Patient may request anaesthesia
 Fiber inserted into pocket (circumferential or not)
• Takes about 10 minutes/tooth
 Some control of saliva
 Should contact pocket base
Must be used in combination with
scaling and root planing

43. Actisite
 Application:
 Sealed in place with adhesive
• Apply in thin even line along gingival margin
• Surgical dressing not necessary but has been used
 Removed 14 days after placement
• Curette and/or cotton pliers
• Fiber comes out in mass or pieces
• Debride areas as necessary
 Tissue may appear red following removal

44. Actisite
 Fewer Adverse effects:
 Discomfort
 Local erythema
 Little systemic reaction
 Used with caution in client with history of
candidiasis
 Application around 12+ teeth may result in
oral candidiasis

45. Actisite
 Patient instructions:
 Avoid brushing & flossing
 Use antimicrobial rinse
• Use of CHX may have synergistic effect
 Avoid hard or crunch foods, stick foods,
chewing gum

46. Actisite
 Clinical Efficacy:
 Reduction in bleeding on probing and pocket
depth
• More significant reductions in deeper pockets
 Reduction in periodontal pathogens

47. PerioChip
 Description:
 Rectangular chip, supplied in boxes of 10
chips
 Contains 2.5 mg Chlorhexidine D-gluconate
 Biodegradable matrix of hydrolyzed gelatin
 Store in refrigerator until use
 2 year shelf life

48. PerioChip
 Mechanism of action:
 Bactericidal antiseptic agent
 Binds with tissue – no need for surgical
dressing
 Chip gradually biodegrades releasing CHX
 Sustained release over period of 7-10 days
 GCF concentrations vary among patients
• Peaks at (2-4) hours after insertion
• Peaks again at approx. 72 hours
• Concentrations gradually decline over 7-10
day period

49. PerioChip
 Recommended dose:
• One PerioChip into one
periodontal pocket
• Not recommended to place
more than 2 chips around
one tooth at one time
• Can be administered once/3
months (PD > 5 mm)

50. PerioChip
 Administration:
 Keep chip refrigerated until ready to use
 Thorough debridement of area to be treated
 Irrigate area to flush out debris
 Dry area
 Grasp chip with non-serrated cotton pliers
 Entire chip must be submerged – use probe
to maneuver chip to pocket base

51. PerioChip

52. Arestin 
 Mechanism of action:
 Broad spectrum
 Bacteriostatic
 GCF levels maintained at high levels for at
least 14 days

53. Arestin
 Clinical use:
 Pockets 5 mm
 How supplied:
 Box containing 2 trays each containing 12
cartridges
 Cartridge contains 1 mg of minocycline
(semisynthetic tetracycline derivative)
microencapsulated in Poly dry powder
 Cartridge inserted into a cartridge handle

54. Arestin 
 Application:
 Insert tip to base of periodontal pocket
 Expel powder into pocket
 Bioadhesive microspheres activate & adhere on
contact with moisture
 Cartridge contains enough Arestin for one
periodontal pocket
 Clinical trials: 30 sites treated in less than 10
minutes
 Dressings or adhesives not required

55. Arestin 
 Preparing for Arestin
Pre-measured, premixed,
no refrigeration necessary

56. Arestin 
 Adverse effects:
 Headache
 Pain
 Mouth ulceration
 Stomatitis

57. Arestin 
 Patient instructions:
 Do not eat hard or sticky foods for 1 week
 Postpone brushing for 12 hours
 Do not use interproximal cleaning aids for 10 days

58. Arestin 
 Clinical efficacy:
 27,000 sites treated,
n=748 pt

59. Arestin 
 Clinical efficacy:
 Arestin with debridement demonstrated
27% greater pocket reduction in molars
compared to debridement alone
• Mean reduction of 2 mm (pockets 7 mm +)
 Effective in furcations

60. Atridox
 A liquid biodegradable drug delivery
system that hardens in the periodontal
pocket and gives a controlled release of
the incorporated agent
 Administered via syringe
 Studies in progress; this material in
conjunction with root planing and scaling

61. Periocline
 Applied into the pocket with a syringe
and blunt cannula
 Reduction in probing pocket depth in
sites treated with scaling and root
planing

62. Elyzol
 Applied with a syringe
 Good clinical effects in when used with
scaling and root planing; bone gain in deep
pockets

63. Controlled Release Agents
 Work by;
 Suppressing destructive enzymes produced
during inflammatory process (collagenase)
 Suppressing microbes
 Considered for localized periodontal sites