Antibiotics and Local Delivery Devices in Periodontology PDF

Antibiotics and Local Delivery Devices In Periodontology Dr.Jafar Naghshbandi D.D.S;M.S Diplomate of the American Board of Periodontology  Special thanks whoever taught me a word make me his servant Dr. Raul caffesse Dr. Jim Simon Antibiotics are classically used in medi...

Antibiotics and Local Delivery Devices In Periodontology Dr.Jafar Naghshbandi D.D.S;M.S Diplomate of the American Board of Periodontology  Special thanks whoever taught me a word make me his servant Dr. Raul caffesse Dr. Jim Simon Antibiotics are classically used in medicine to eliminate infections caused by the invasion of the host by foreign, pathogenic microorganism  ANTIBIOTIC: A chemical substance produced by microorganisms having the property ANTIBIOTIC of inhibiting the growth of or destroying other microorganisms TERMINOLOGY CHEMOTHERAPY: DEFINITION Treatment of systemic infections with specific drugs that selectively suppress the infecting microorganism without significantly affecting the host  TERMINOLOGY Antimicrobial - This term refers to both antibiotics and synthetic agents active against microbes. Microcidal - (Bacteriocidal. Virucidal, Fungicidal) The organism is lysed or killed by direct damage on susceptible cell targets. Microstatic - (Bacteriostatic, Virostatic, Fungistatic) The organism is reversibly inhibited at specific metabolic processes. Action and host defense mechanisms: Multiplication of the organism is inhibited  Narrow Spectrum Antimicrobial : - An antimicrobial that acts on a limited number of microbial species, e.g. Nitroimidiazole derivatives etc TERMINOLOGY Broad Spectrum Antimicrobial : - An antimicrobial that acts on a wide range of species, e.g., erythromycin for Gram positive. Gram negative, Legionella, Mycoplasma, etc.  SPECTRUM OF ACTIVITY Narrow spectrum: Penicillin G, streptomycin and erythromycin. Broad spectrum: Tetracyclines, chloramphenicol. Extended spectrum: Semi synthetic Penicillins, new cephalosporins, aminoglycoside.  Antibiotic Strategies Cardinal Rules: 1) Use the right drug. 2) Use the right dose. 3) Use the correct dosing schedule. 4) Correct duration. Hard and Fast—Especially early. Why? Use a loading dose to rapidly achieve therapeutic blood levels INDICATIONS for ANTIBIOTICS 1. Severity of the infection - Acute onset - Diffuse swelling involves fascial spaces 2. Adequacy of removing the source of infection - During drainage can’t be established immediately 3. The state of patients’ host defense - When the patient is pyretic - Compromised host defenses - For prophylaxis Why to administer antibiotic in periodontal Disease?!!! Periodontal disease is associated with bacteria and treatment by chemotherapeutic agents appears to be effective Chemotherapeutic agents are administered : Systemically Delivered locally CHOICE OF ANTIBIOTICS May be based on More often, the choice microbiological of antibiotic is analysis of the samples empirical and based obtained from affected on the clinical signs sites  Antibiotics Narrow Extended Broad Penicillin G, V Cephalosporin Tetracycline Erythromycin Extended spectrum penicillins Metronidazole Penicillinase resistant penicillin Vancomycin Indications for antibiotics in periodontal therapy Acute infections Aggressive (early onset) forms of periodontitis Recurrent (“refractory”) periodontitis Severe cases of acute necrotizing ulcerative gingivitis and periodontitis Multiple abscess formation and gross periodontal infection Localized Aggressive Periodontitis  Localized Aggressive Periodontitis Antibiotic therapy: Adjunctive therapy often required to eliminate A.a. from tissues Tetracycline (250 mg qid for 2 weeks) Metronidazole combined with amoxicillin Doxycycline The earlier the condition is diagnosed, the sooner tx can begin – outcome often more predictable  Localized Aggressive Periodontitis Antibiotic therapy: Adjunctive therapy often required to eliminate A.a. from tissues Tetracycline (250 mg qid for 2 weeks) Metronidazole combined with amoxicillin Doxycycline The earlier the condition is diagnosed, the sooner tx can begin – outcome often more predictable Common Pathogens in Periodontal Diseases Gingivitis: Fuso, strep, & actinomycetes Adult peritonitis: Bacteroides, porphyomonas, peptostreptococcus & prevotella Acute necrotizing ulcerative gingivitis: Spirochetes, prevotella, fuso Localized juvenile periodontitis: Actinobacillus Common Pathogens in Fungal Infections: Candida spp. Mucorales spp  Mechanism of action Inhibit cell wall synthesis Cause leakage from cell membrane Inhibit protein synthesis Inhibit DNA gyrase (involved in the control of topological transitions of DNA) Cause misreading of m-RNA code and affect permeability. Interfere with DNA function Interfere with DNA synthesis, etc Antibiotics Used in Periodontal Therapy Penicillins (e.g., amoxicillin Tetracyclines (e.g., doxycycline) Metronidazole Fluoroquinolones (e.g., ciprofloxacin) Clindamycin Erythromycin Azithromycin Penicillins Bactericidal Reach effective levels in gingival fluid Don’t inhibit all A.a. Strains Inactivated by ß-lactamases Amoxicillin has enhanced tissue penetration and good activity against gram negatives Augmentin is as effective as amoxicillin, but resists inactivation by ß-lactamases Penicillins Penicillins inhibit bacterial cell-wall synthesis Natural penicillins (narrow spectrum) Amoxicillin is a semi-synthetic penicillin Broadened antimicrobial spectrum used in periodontology because it is effective against some subgingival bacterial species such as P. micros & A.actinomycetemcomitans Penicillins cont… Can be used in cases of acute infections Most commonly used in combination with metronidazole Amoxicillin in combination with clavulonic acid is indicated in the presence of oral bacteria capable of producing β-lactamase 2  Tetracyclines Group of broad spectrum antibiotics Bacteriostatic antibiotics This group includes tetracycline hydrochloride, minocycline and doxycycline Regularly used in treatment of refractory periodontitis including localised aggressive periodontitis. Concentrate in periodontal tissues(conc. in gingival crevice is 2 to 10 times more than in serum)& inhibit the growth of a.a. Exert anti collagenase effect  Obtained naturally from streptomyces sps. or derived semisynthetically More effective against gram +ve than gram -ve bacteria Pharmacology Their conc. in gingival crevice is 2 to 10 of times more than in serum Tetracycline Tetracycline –Dose 250 mg four times daily (qid) Inexpensive but less patient compliance  Minocycline Broad spectrum of activity Dose 200 mg/day Given twice daily (bid) so better patient compliance Less side effects than tetracycline More effective against spirochetes and motile rods Doxycycline Same spectrum of activity as minocycline Given once daily so more patient compliance Dose as an anti infective agent is 100mg bid the first day, then 100mg qd As subantimicrobial dose ( to inhibit collagenase) 20mg twice daily Side effects Liver damage Kidney damage Phototoxicity Chelating effects-teeth & bones Hypersensitivity Super infections  Metronidazole is a synthetic nitroimidazole Bactericidal Metronidazole Acting on anaerobic bacteria, including gram- negative rods and spirochetes, through DNA synthesis blocking Due to the susceptibility of the spirochetes, it is effective in cases of necrotizing periodontal diseases  Relatively ineffective in the suppression of A. actinomycetemcomitans. Its antimicrobial spectrum Metronidazole cont… is not wide enough for treatment of aggressive periodontitis Antibiotic of a choice for Periodontal abscesses  flagyl,metrogyl Dose- 250mg/tds/oral Adverse effects Anorexia, nausea Abdominal cramps Metallic taste, headache, glossitis,dryness of mouth Contraindication Neurological disease First trimester of pregnancy Chronic alcoholism  Fluoroquinolones (Ciprofloxacin) A quinolone active against gram –ve rods Bactericidal Extremely active against A.a., but less active against anaerobic bacteria Reach higher levels in gingival fluid than in blood serum Penetrate epithelial cells-can kill invasive bacteria  Effective in the treatment of periodontal super infections caused by enteric bacteria, pseudomonas or staphylococci Additional positive aspect Ciprofloxacin Inactivity towards streptococci, whose presence in the subgingival area is associated with periodontal health. Heightened streptococcal counts can postpone recolonisation of the pathogenic bacterial species  Ciprofloxacin CIFRAN,CIPLOX- 200,500mg tab Side effects Gastrointestinal CNS effects Hypersensitivity reaction  Clindamycin Potent bacteriostatic activity against strict anaerobes Less effective against facultative pathogens (A.a. and Eikenella) Can induce ulcerative colitis Often used as an alternative antimicrobial agent in penicillin-allergic patients Clindamycin cont…. DOSE 150-300mg QID ORAL, Side effects Rashes Urticaria (Hives) a kind of skin rash with red, raised, itchy bumps. Abdominal pain Pseudomembranous entrocolitis  Erythromycin DOESN’T REACH WEAK ACTIVITY EFFECTIVE AGAINST A.A., CONCENTRATIONS EIKENELLA AND IN GINGIVAL FLUID FUSOBACTERIUM  Azithromycin From the macrolide group Bacteriostatic activity by blocking of bacterial proteins synthesis Broad spectrum, covers gram-negative bacteria, including enteric bacteria Good activity against A.a. and Eikenella, P. gingivalis and many other gram- negative anaerobes Penetrates epithelial cells-can kill invasive bacteria  Dose Therapeutic use : Single dose of 250 mg/day for 5 days after an initial loading dose of 500mg Has extremely high values in periodontal tissues, crevicular fluid and saliva Periodontally inflamed tissues exhibit Azithromycin concentrations significantly higher than healthy periodontal tissues, which is a very convenient characteristic of this antibiotic Data from clinical investigations: support the use of azithromycin in the treatment of advanced chronic, or aggressive periodontitis  Systemic Antibiotic Regimens for Treating Aggressive and Recurrent Periodontitis Tetracycline HCl (250 mg QID) for 21 days (one of the oldest regimens) Amoxicillin (500 mg TID) and metronidazole (250 mg TID) for 8 days (most commonly prescribed-more effective than a single agent) Metronidazole (500 mg BID) and ciprofloxacin (500 mg BID) for 8 days (usually very effective for mixed infections)  Limitations of Systemic Antibiotics in Periodontics Antibiotics rarely enhance the treatment of chronic periodontitis To eliminate bacteria in biofilms effectively, antibiotics must be used in conjunction with mechanical debridement No single antibiotic can inhibit all periodontal pathogens Antibiotics can have unwanted side effects when given systemically  Side Effects Associated With Systemic Antibiotics Induction of antibiotic resistance Induction of microbial overgrowth Inhibition of oral contraceptives (rare) Hypersensitivity or toxicity (e.g., allergy, nausea, diarrhea, photosensitivity)  Local Delivery Devices FIBERS STRIPS AND FILMS INJECTABLE GELS COMPACTS SYSTEMS Advantages 1. Improve patient acceptance and compliance 2. Better possibility for direct access to target various periodontal diseases 3. Avoidance of GI tract problems with oral drug administration Alternative drug administration in patient who are not able to swallow Bypasses the metabolism by the liver Safe and convenient route Noninvasive, painless, and simple application Limitations 1.Dose limitation because of relatively small area 2.Pre-systemic metabolism could occur by the enzymes like peptidase and esterase 3.It should be devoid of irritancy or sensitization 4.Cost should be taken in consideration