Informative & comprehensive presentation. Brief guide on Antibiotics used for periodontal diseases. Courtesy Dr. Faran Farooq

2. Dr. Faran Farooq
House officer
Periodontology department

3. Objectives
• Chemotherapeutic agents in periodontal diseases.
• Contribution of Antimicrobials in Periodontal diseases.
• Brief knowledge of Antimicrobials used in Periodontal diseases.

4. Pathogenesis of Periodontal Diseases

6. Chemotherapeutic Agents
• Anti-Infective Agents
“Agent that works by reducing the
number of bacteria present”

7. • Antibiotics/Antimicrobial Agents
“Naturally occurring synthetic or semi synthetic type
of anti-infective agents that destroy or inhibits
the growth of selective micro-organism generally
at low concentration.”

8. • Antiseptic Agents
“Chemical antimicrobial agent applied topically
or sub-gingivally to mucous membrane wounds
or intact dermal surfaces to destroy micro-organism
or inhibit their reproduction or metabolism.”

9. Antibiotics/Antimicrobial Agents
• SYSTEMIC ADMINISTRATION
• LOCAL ADMINISTRATION

10. SYSTEMIC ADMINISTRATION
• May be a necessary adjunct in controlling bacterial infection because bacteria
can invade periodontal tissues making mechanical therapy alone
sometimes ineffective.
• Antibiotics provide a useful adjunct to root planning, which by itself may
not remove all subgingival deposits and certainly would not affect any
invading organisms that had already penetrated the SOFT TISSUE.

11. Contribution of Antibiotics
• Systemic antimicrobials are released from the pocket wall into the GCF.
• The susceptibility of bacteria to the antibiotics may be the key to the efficacy
of systemic antibiotics in the treatment.

12. • Systemic antimicrobial therapy should be an adjunct to mechanical a
comprehensive periodontal treatment plan.
• The antibiotic required 500 times greater strength then systemic therapeutic
dose to be effective against the bacteria arranged in intact BIOFILMS
• It is therefore important to disrupt the biofilm physically.

13. Health
Oral hygiene
Root debridement
Supportive periodontal therapy
Surgical access for root debridement
Regenerative therapy
ANTIBIOTICS as indicated by microbial analysis
Aggressive, refractory or
medically related
periodontitis
Chronic
periodontitis
Microbial
analysis
IneffectiveEffective
Supportive periodontal treatment
Guideline for the use of antimicrobial therapy

14. INDICATIONS FOR ANTIBIOTICS IN
PERIODONTAL THERAPY
• local infection of a periodontal abscess can spread within tissue planes
to cause marked facial swelling and systemic involvement
• Acute Necrotizing Ulcerative Gingivitis ANUG
• Multiple abscess formation and gross periodontal infection
• Localized aggressive periodontitis LAP

15. IDEAL ANTIBIOTIC for periodontal disease
• Used in prevention & and treatment of periodontal disease
• Specific for periodontal pathogens
• Allogenic
• Non toxic
• Substantive
• Not in general use for treatment of other disease.
• inexpensive

16. CURRENTLY
NO SUCH
ANTIBIOTIC EXIST!!!!!!

17. So what????
• Oral bacteria are susceptible to many antibiotics.
• Unfortunately there is no single antibiotic i.e. (no “silver bullet”) at
concentration achieved in body fluids that inhibit all putative periodontal
pathogens.
• Indeed a combination of antibiotics may be necessary to eliminate
putative pathogens from periodontal pockets.

18. Selection of an ANTIBIOTIC
• Patients’ clinical status
• History of the disease
• Clinical signs & symptoms
• Radiographic aid
• Microbiologic sampling (if possible)
Plaque sampling is done by the help of paper points

20. Common Antibiotics Regimens
Antimicrobial Agent Regimen Dosage/Duration
Amoxicillin 500mg TDS for 8 days
Azithromycin 500mg OD for 4-7 days
Ciprofloxacin 500mg BD for 8 days
Clindamycin 300mg TDS for 10 days
Doxycycline/minocycline 100-200mg OD for 21 days
Metronidazole 500mg TDS for 8 days
Metronidazole + Amoxicillin 250mg f each TDS for 8 days
Metronidazole + Ciprofloxacin 500mg of each BD for 8 days

21. TETRACYCLINES
Actisite , Robitet 500
• Produced from Streptomyces.
• Bacteriostatic.
• Protein synthesis inhibitor. (30s microsomal subunit)
• Effective against multiplying bacteria.
• Broad spectrum!! Activity against both Gram-positive and Gram negative
species
• Concentration In GCF is 2-10 times than in serum.

22. • Investigated as an important in adjunct in LAP
• Activity against A.actinomycetemcomitans
• Dual action!!! Antimicrobial + host modulation (inhibit Collagenase)
• So! Reduce bone destruction & Aid regeneration.

23. Minocycline [cinocid , cycloxin]
 Adult periodontitis
 Spirochetes & motile rods
 200mg/day for 21 days
 Less phototoxicity , renal toxicity than tetracycline.
 Reversible vertigo is one of the side effect

24. Doxycycline
Similar spectrum as minocycline
Can be given OD so better compliance
100mg OD for 21 days.
Marked anti-collagenase effect.
Vibramycin 100mg
Nordox
Ardox

25. Metronidazole
• Nitromidazole compound
• Bactericidal
• Disrupt bacterial DNA synthesis.
• The antibacterial activity against anaerobic cocci,
anaerobic Gram - negative bacilli, and anaerobic Gram - positive
bacilli
Flagyl 400mg, 200mg
Gramex 400mg

26. • effective against A.actinomycetemcomitans in combination with other
antibiotics.
• Also effective against anaerobes such as porphyromonas gingivalis & provetella
intermedia
• Successfully used to treat ANUG
• Chronic periodontitis, aggressive periodontitis, clinically significant
gingivitis.

27. • 750-1000mg/day for 2 weeks reduces the anaerobic flora & decreases
histopathologic signs of periodontitis.
• Most common regimen is 250mg TDS for 7 days.

28. • Cramps , nausea , vomting results due to interaction with alcohol.
• Avoid alcohol.
• Inhibits warafrin metabolism so avoid in patients with anticoagulant
therapy.
• Avoid in patients taking LITHIUM
• Metallic taste.

29. Penicillin
• Bactericidal
• Cell wall inhibitor.
Amoxicillin
 Aggressive periodontitis generalized & localized both
500mg for 8 days.
Amoxil 250,500mg

30. Amoxicillin-clavulanic acid
LAP
Refractory periodontitis
Bacterial resistance to penicillin is a curse!!
Augmentin 375, 625 mg

31. 10% of the patients are resistant
to penicillin

32. Clindamycin
• Anaerobic bacteria.
• In case of penicillin allergy.
• Recommended dosage 150mg QDS for 10days.
300mg BD for 8 days.
• pseudomembranous colitis, diarrhea , GI upsets

33. Ciprofloxacin
Ciprox , ciclox
• Quinolones.
• Gram negative rods, all facultative & some anaerobic.
• It is the only antibiotic to which all strains of A.actinomycetemcomitans are
susceptible
• Nausea, metallic taste , abdominal discomfort
• 500mg BD for 8 days with or without Metronidazole.

34. Macrolides
• Bacteriostatic or bactericidal depending on concentration.
Erythromycin , Spiramycin
Azithromycin
Anaerobes , gram negative bacilli.
500mg OD for 4 -7 days
Zithromax
Zmax
Azomax 250mg

35. Serial & Combination Antibiotic Therapy
• Bacteriostatic antibiotic (e.g. tetracycline) require rapidly dividing
microorganism to be effective SO not function well if bactericidal antibiotic
(e.g. amoxicillin) is given concurrently. They are best given serially.
Metronidazole + Ciprofloxacin (POWERFULL COMBINATION)
effective against A.actinomycetemcomitans
Metronidazole against obligate anaerobes.
Ciprofloxacin against facultative anaerobes

36. Metronidazole + amoxicillin / Augmentin
Adult localized periodontitis , refractory to tetracyclines.
Additive effect against A.actinomycetemcomitans
250mg of each TDS for 8 days.

37. LOCAL ADMINISTRATION
• Local delivery antibiotics are recommended as adjuncts to scaling and root
debridement, and not as stand-alone treatments.
• Fewer side effects, and fewer chances of resistant bacteria forming
• The concentration of the antibiotic at the diseased site can be 100 times
greater than taking the medication orally i.e systemically.

38. Tetracycline containing fibers Actisite®
12.7 mg / 9 inches
Well tolerated , placed for 10 days
Concentration in GCF is 1300 Ugm/ml compared to 4-8mg by
sys. Administration.

40. Subgingival Doxycycline
 10% doxycycline in a gel system (ATRIDOX)

41. Subgingival Minocycline
 ARESTIN Small spheres of minocycline 2% , a derivative of tetracycline is
very effective in killing the bacteria that are thought to cause periodontal
disease

43. Subgingival Metronidazole
Topical medication containing oil based metronidazole 25%
dental gel.

44. Take Home Message
ALWAYS EVALUATE THE PATIENT FOR THE INDICATIONS TO
ANTIBIOTIC THERAPY

45. Bibliography
Carranza’s Clinical periodontology 10th edition.