Use of Antimicrobials in Periodontal Clinical Practice

1. Anti infective therapy in
Periodontal Disease
Dr Saif khan
MDS PhD(Periodontology)
Assistant Professor
Deptt of Periodontics & Community Dentistry
Dr Z A Dental College & Hospital, Faculty of Medicine,
Aligarh Muslim University,
Aligarh,

2. Periodontal disease
• Host-Microbe Interaction disease
• Plaque-Host associated biofilm; Highly
complex entity
• Mechanical Therapy- Mainstay treatment
• Anti infective Therapy- Adjunct

4. Periodontal
therapy
History
Radiographic
examination
Microbiological
sampling
Clinical Signs &
Symptoms

5. Chemotherapeutic agent
• Chemical substance that provides clinical therapeutic
benefits
• Clinical benefits
– Antimicrobial action
– Increased Host Resistance
Anti infective agent : A chemotherapeutic agent that
works by reducing the number of bacteria present
Antibiotic: Naturally occurring ,semisynthetic,
synthetic type of anti infective agent that destroys
or inhibits growth of selective microorganisms at
low concentrations

6. • Antiseptics – Chemical antimicrobial agent
applied topically or subgingivally to mucous
membranes, wounds, or intact dermal
surfaces to destroy microorganisms and
inhibit their reproduction or metabolism
• Antiseptics in dentistry- Antiplaque &
Antigingivitis oral rinses and dentrifices
• Antiinfectants: Antimicrobial agent used on
inanimate surface to destroy microorganisms

7. • Chemotherapeutic agent
– Local delivery
– Systemic delivery
Purpose: To reduce the number of bacteria present
in the diseased periodontal pocket
Systemic administration of the antibiotics may be a
necessary adjunct in controlling bacterial infection
because bacteria can invade periodontal tissues
making mechanical therapy ineffective

8. • Local administration of Anti infective agents
directly in the pocket has the potential to
provide greater concentration directly to
infected area and reduce possible systemic
side effects

9. • Antibiotic used for Periodontal disease in
prevention and treatment should be
– Specific for Periodontal pathogen
– Non-toxic
– Substantive
– Inexpensive
– Not in general use for treatment of other diseases

10. • Currently, An ideal antibiotic for treatment of
periodontal disease does not exist
• Although oral bacteria are susceptible to many
antibiotics- No single antibiotic concentration
achieved in body fluids inhibit all putative
periodontal pathogens
• Combination of Antibiotics may be necessary
to eliminate all putative periodontal pathogen

11. • The overuse, misuse and widespread
prophylactic application of anti microbial drugs
have lead to development of anti microbial
resistance (AMR) in microorganisms towards
the particular antimicrobial agent
• Increased level of AMR has been correlated
with increased use of antibiotics in individual
countries
• Subgingival microflora tends to revert to similar
proportion of antibiotic resistance isolate 3
months after therapy

12. Guidelines
• Clinical diagnosis and situation dictate the
need for possible antibiotic therapy as adjunct
in controlling periodontal disease- Refractory
/Aggressive perioodntitis
• Continuing disease activity(Continuing
attachment loss, Purulent exudate, PPD≥ 5mm
with BOP- Periodontal intervention; Microbial
analysis(Plaque sampling)

13. • Antibiotics are selected based on patients medical
and dental status, current medications and result
of microbial analysis if performed
• Microbial plaque sampling;
– The samples are taken at the beginning of appointment
before instrumentation of the pocket
– Supragingival plaque is removed and an endodontic
paper point is inserted into deepest pocket(s) present
to absorb bacteria in the loosely associated plaque.
The endodontic point is placed in reduced transfer fluid
and sent overnight to laboratory

14. • Plaque sampling can be performed at the
initial examination, root planning,
reevaluation or SPT appointment
• Clinical indication for plaque sampling ;
– Aggressive periodontal disease
– Periodontal disease refractory to mechanical
therapy
– Systemic condition

15. • Debridement of root surfaces, optimal oral
hygiene and frequent supportive periodontal
therapy are important parts of comprehensive
periodontal therapy
• Antibiotic strength 500 times greater than
systemic dose may be required to be effective
against bacteria in biofilm
• It is important to disrupt the biofilm so that
antibiotics can have access to periodontal
pathogen

16. • The clinician must integrate history of
patient’s disease, clinical sign and symptoms,
and results of radiographic examinations and
possibly microbial sampling to determine the
course of periodontal therapy
• The clinician must obtain thorough medical
history, including current medications and
possible adverse effects of combining these
medicines, before prescribing any antibiotic
therapy

17. Guidelines for Antimicrobial therapy in Periodontal disease

18. Tetracyclines
• Group of antibiotics produced naturally from
certain species of streptomyces or derived
semisynthetically
• Bacteriostatic
• Concentration in GCF 2 to 10 times the serum
• Tetracycline at low GCF concentration(2-
4µg/ml) are very effective against periodontal
pathogens
• Clinical use- LAP
• Dose: 250 mg four times daily (QID)

19. Minocycline
– Semisynthetic tetracycline
– Less phototoxic and Renal toxic than Tetracycline
– Administered orally 200mg/day for 1 week
– Reduction in bacterial count
– Complete elimination of spirochetes up to 2
months

20. Doxycycline
• Same spectrum as Minocycline
• Can be given orally once daily-More
Compliance
• Absorbtion from GIT slightly altered by Ca
,Antacids, Metal ions
• 100mg Antimicrobial dose
• 20 mg Host Modulation Therapy dose

21. Metronidazole
• Nitroimidazole compound
• Bactericidal to Anaerobic Microorganism
• Disrupts DNA synthesis in condition with low
reduction potential
• Indications; ANUG, C P, Ag P
• 250mg thrice daily for 7 days

22. Penicillin
• Natural and Semisynthetic derivatives of broth
cultures of the Penicillium mold
• Inhibit bacterial cell wall- Bactericidal
• Allergic
• Bacterial resistance

23. Amoxycillin
• Semisynthetic Penicillin with extended anti
infective spectrum (Gm+ & Gm- bacteria)
• Excellent absorption after oral administration
• Susceptible to Penicillinase (Bacteria) which
renders it ineffective by breaking Penicillin
ring
• Indications: LAP,GAP
• Recommended Dose: 500mg tid for 5 days

24. Amoxycillin-Clavulanate Potassium
• Combination of Amoxycillin and Clavulanate
potassium is resistant to Penicillinase Enzyme
which breaks penicillin ring
• Indication: Refractory Perioodntitis,LAP

25. Clindamycin
• Used when patient is allergic to Penicillin
• Effective against Anaerobic bacteria
• Side effects: Pseudomembranous
Colitis,Diarrhoea

26. Ciprofloxacin
• Quinolone active against Gram Negative
Rods,including all facultative and some anaerobic
putative periodontal pathogens
• Only Antibiotic to which all strains of Aa are
susceptible
• Can also be used in combination with Metronidazole
• ADR: Nausea, headache, Metallic taste, Enhance
effects of Warfarin and anticoaglants, Toxicity of
Theophylline and Caffeine

27. Macrolide
• Many member Lactone ring to which one or
more De-oxy sugars are attached
• Inhibit protein synthesis by attaching to 50s
ribosomal subunit of microorganism
• Bacteriostatic and Bactericidal depending on
Concentration of Drug
• Macrolide antibitics used in Periodontal
treatment; Spiramycin,Azithromycin

28. Rationale
• Periodontal infection involves wide diversity
of bacteria(700) therefore no single
antimicrobial is effective against all
periodontal pathogens
• Periodontal disease is a mixed infection
polymicrobial; use of more than one antibiotic
either serially or in combination is advised
• Before combination therapy periodontal
pathogen(s) must be identified and antibiotic
susceptibility performed

29. • Bacteriostatic (Tetracycline) and
Bactericidal(Penicillin) are best given serially,
not in combination
• Combination therapy
– Amoxycillin+ Metronidazole
– Amoxycillin+ Clavulanate (Augmentin)
– Ciprofloxacin+ Metronidazole

30. Sequencing of antimicrobial therapy

31. Local Drug Delivery
• Tetracycline containing fibres(Actisite);
– Ethylene/Vinyl acetate copolymer fiber(D=0.5mm)
– Tetracycline 12.7mg per 9inch
– Tetracycline GCF concentration achieved;
1300µg/ml
– 32-64 µg/ml GCF concentration required to
inhibit growth of periodontal pathogens
– 4-8µg/ml GCF concentration achieved by systemic
Tetracycline 250 mg qid for 10 days(Total dose
10gm)

32. Placement of Actisite fiber

33. • Subgingival Chlorhexidine (Periochip)
– Resorbable delivery system subgingival placement of
chlorhexidine
– Periochip is a small chip (4×5×0.35mm) composed of
2.5mg chlorhexidine incorporated in a biodegradable
hydrolysed gelatin matrix crosslinked with
glutraldehyde with glycerine and water
– CHX GCF concentration greater than 100µg/ml is
maintained for 7 days
– Chip biodegrades in 7 to 10 days

35. Subgingival doxycycline (Atridox):
10% doxycycline in gel system in syringe

36. Subgingival Minocycline (Arestin):
Local delivered sustained release form of minocycline
microsphere(Arestin)
2% Minocycline in encapsulated into bioresorbable
microsphere in a gel carrier