This document discusses the use of anti-infective agents in treating periodontal diseases. It outlines that both systemic antibiotics (oral) and local delivery can reduce bacterial loads. Common agents discussed include tetracyclines, metronidazole, penicillins, and macrolides. Guidelines recommend selecting antibiotics based on diagnosis and bacterial analysis, and using them as an adjunct to scaling and root planing to improve outcomes like attachment levels. Local delivery options like chlorhexidine chips, doxycycline gel, and minocycline microspheres can maintain drug levels in the gingival crevicular fluid.

1. Anti-infective
Therapy
IN PERIODONTAL TTT

2.  An anti-infective agent is a chemotherapeutic agent that acts by
 reducing the number of bacteria present
 Many chemotherapeutic agents are now available to clinicians who treat
periodontal diseases.
 Systemic anti-infective therapy (oral antibiotics) and local
 anti-infective therapy (placing anti-infective agents directly into
 the periodontal pocket) can reduce the bacterial challenge to the
 periodontium.

3. Mechanism of destruction
 Bacteria and their toxic products cause a loss of attachment and
 a loss of bone. Ultimately, however,
 the host’s own immunologic
 response to this bacterial infection can cause even more bone
 destruction (i.e., indirect bone loss) than that caused by pathogenic
 bacteria and their by-products

4. How to act
 Chemotherapeutic
 agents can modulate the host’s immune response to bacteria and
 reduce the host’s self-destructive immunologic response to bacterial
 pathogens, thereby reducing bone loss

5.  Anti-infective agents can be administered locally or orally.
 When administered orally, many of these agents can be found
 in gingival crevicular fluid (GCF).

6.  The systemic administration of antibiotics
 may be a necessary adjunct for the controlling of bacterial infection,
 because bacteria can invade periodontal tissues, thereby
 making mechanical therapy alone sometimes ineffective

7.  A single chemotherapeutic agent can also have a dual mechanism
 of action. For example, tetracyclines (especially doxycycline)
 are chemotherapeutic agents that can reduce collagen and bone
 destruction via their ability to inhibit the enzyme collagenase

9.  no single antibiotic at the concentrations achieved in body fluids
 inhibits all putative periodontal pathogens.
 Indeed, a combination of antibiotics may be necessary to eliminate all
putative pathogens
 from some periodontal pockets

11.  the treatment
 of the individual patient must be based on the patient’s clinical
 status, the nature of the colonizing bacteria, the ability of the
 agent to reach the site of infection, and the risks and benefits

12. Tetracyclines
 Tetracyclines have been widely used for the treatment of periodontal
 diseases. They have been frequently used to treat refractory
 periodontitis, including localized aggressive periodontitis (LAP)
 . Tetracyclines have the ability to concentrate in
 the periodontal tissues and to inhibit the growth of Aggregatibacter
 actinomycetemcomitans.
 In addition, tetracyclines exert an anticollagenase
 effect that can inhibit tissue destruction and that may
 help with bone regeneration

13.  Systemic tetracycline can eliminate tissue bacteria, and it
 has been shown to arrest bone loss and to suppress A.
actinomycetemcomitans levels in conjunction with scaling and root
planing

14. Specific Agents. Tetracycline, minocycline, and doxycycline
are semisynthetic members of the tetracycline group that have
been
used in periodontal therapy.
 Minocycline. Minocycline is effective against a broad spectrum
 of microorganisms. In patients with adult periodontitis, it suppresses
 spirochetes and motile rods as effectively as scaling and
 root planing, with suppression evident up to 3 months after therapy.

15.  Minocycline administered at a dose
 of 200 mg/day for 1 week results in a reduction in total bacterial
 counts, the complete elimination of spirochetes for up to 2 months,
 and the improvement of all clinical parameters

16.  Doxycycline. Doxycycline has the same spectrum of activity
 as minocycline, and it may be equally as effective

17. The recommended dosage when doxycycline is used as an antiinfective
agent is 100 mg twice daily the first day, which is then
reduced to 100 mg daily. To reduce gastrointestinal upset, 50 mg
can be taken twice daily after the initial dose. When given as a
sub-antimicrobial dose (to inhibit collagenase), 20 mg of doxycycline
twice daily is recommended

18. Metronidazole
 It
 is bactericidal to anaerobic organisms,
 Metronidazole is not the drug of choice for treating
 A. actinomycetemcomitans infections. However, metronidazole is
 effective against A. actinomycetemcomitans when it is used in
 combination with other antibiotics

19.  Metronidazole has been used clinically to treat
 gingivitis, acute necrotizing ulcerative gingivitis, chronic periodontitis,
 and aggressive periodontitis. It has been used as monotherapy
 and also in combination with both root planing and surgery
 or with other antibiotics. Metronidazole has been used successfully
 to treat necrotizing ulcerative gingivitis

20.  The most
 common regimen is 250 mg three times daily for 7 days.

21. Penicillins
 Amoxicillin. Amoxicillin is a semi-synthetic penicillin with an
 extended anti-infective spectrum that includes gram-positive and
 gram-negative bacteria. It demonstrates excellent absorption after
 oral administration.
 Amoxicillin–Clavulanate Potassium. The combination
 of amoxicillin with clavulanate potassium makes this anti-infective
 agent resistant to penicillinase enzymes produced by some bacteria.
 Amoxicillin with clavulanate (Augmentin) may be useful for
 the management of patients with LAP or refractory periodontitis

22.  Amoxicillin–Clavulanate Potassium. The combination
 of amoxicillin with clavulanate potassium makes this anti-infective
 agent resistant to penicillinase enzymes produced by some bacteria.
 Amoxicillin with clavulanate (Augmentin) may be useful for
 the management of patients with LAP or refractory periodontitis

23. Cephalosporins
Cephalosporins are generally not used to treat
dental-related infections. The penicillins are superior to cephalosporins
with regard to their range of action against periodontal
pathogenic bacteria

24. Clindamycin
 Clindamycin is effective against anaerobic
 bacteria, and it has a strong affinity for osseous tissue. It is effective
 for situations in which the patient is allergic to penicillin
 Clindamycin has demonstrated efficacy in
 patients with periodontitis that is refractory to tetracycline therapy.
 recommend a
 regimen of 300 mg twice daily for 8 days.

25. Ciprofloxacin
 ciprofloxacin is the only antibiotic in periodontal therapy to which
 all strains of A. actinomycetemcomitans are susceptible. It has also
 been used in combination with metronidazole
 Quinolones
 have also been reported to enhance the effect of warfarin and other
 anticoagulants

26. Macrolides
 The macrolide antibiotics
 used for periodontal treatment include erythromycin, spiramycin,
 and azithromycin
 erythromycin is not recommended as an adjunct to
 periodontal therapy.due to little GCF level
 Spiramycin It is used as an adjunct
 to periodontal treatment in Canada and Europe Spiramycin has a minimal
effect on
 increasing attachment levels

27.  Azithromycin is a member of the azalide class of macrolides.
 It is effective against anaerobes and gram-negative bacilli
 Therapeutic use requires a single
 dose of 250 mg/day for 5 days after an initial loading dose of
 500 mg
 The warning stated that physicians
 should use caution when giving the antibiotic to patients who
 are known to have this condition or who are at risk for cardiovascular
 problems.

28. Guidelines for the use of antibiotics in periodontal
therapy include the following
1. The clinical diagnosis and situation dictate the need for possible
 antibiotic therapy as an adjunct for controlling active periodontal
 Disease
 2. Disease activity as measured by continuing attachment loss,
 purulent exudate, and bleeding on probing56,57 may be an indication
 for periodontal intervention and possible microbial analysis
 through plaque sampling
 3. When they are used to treat periodontal disease, antibiotics are
 selected on the basis of the patient’s medical and dental status

29.  4. When systemic antibiotics were used as adjuncts to scaling and
 root planing, improvements were observed in the attachment
 levels of patients with chronic and aggressive periodontitis,
 although patients with aggressive periodontitis experienced
 greater benefits it ranged from 0.09 mm to 1.10 mm
 5.

32. Local Delivery Agents
 Subgingival Chlorhexidine
 A resorbable delivery system has been tested for the subgingival
 placement of chlorhexidine gluconate with positive clinical results

33.  The PerioChip is a small chip
 (4.0 mm × 5.0 mm × 0.35 mm) that is composed of a biodegradable
 hydrolyzed gelatin matrix. It is cross-linked with glutaraldehyde,
 and it also contains glycerin and water into which 2.5 mg
 of chlorhexidine gluconate has been incorporated per chip. This
 delivery system releases chlorhexidine and maintains drug concentrations
 in the GCF of more than 100 μg/ml for at least 7 days
 these concentrations are well above the tolerance of most oral
 bacteria. Because the chip biodegrades within 7 to 10 days, a
 second appointment for removal is not needed.

35.  Subgingival Doxycycline
 A gel system involving the use of a syringe with 10% doxycycline
 (Atridox)

37.  Subgingival Minocycline
 A locally delivered, sustained-release form of minocycline microspheres
 (Arestin) is available for subgingival placement as an
 adjunct to scaling and root planing . The 2% minocycline
 is encapsulated into bioresorbable microspheres in a gel
 carrier.

39.  Subgingival Metronidazole
 A topical medication that contains an oil-based metronidazole 25%
 dental gel (glyceryl monooleate and sesame oil) has been tested in
 a number of studies

40. Application
 It is applied in a viscous consistency to the pocket, where
 it is liquidized by the body heat and then hardens again, forming
 crystals when it comes in contact with water. As a precursor, the
 preparation contains metronidazole–benzoate, which is converted
 into the active substance by esterases in GCF. Two 25% gel applications
 at a 1-week interval have been used