Antimicrobial Adjuncts in Periodontal Disease Management PDF

Antimicrobial Adjuncts in the Management of Periodontal Disease Asst. Prof. Ayşe Ege Selman  complex of microorganisms that attach to the crown of teeth BIOFILM SUPRAGINGIVAL SUBGINGIVAL PLAQUE...

Antimicrobial Adjuncts in the Management of Periodontal Disease Asst. Prof. Ayşe Ege Selman  complex of microorganisms that attach to the crown of teeth BIOFILM SUPRAGINGIVAL SUBGINGIVAL PLAQUE PLAQUE PERIODONTAL BONE LOSS POCKET ex: p.gingivalis (Greenstein G, 2005, Compend Contin Educ Dent)  post imological response is responbile for tissue distruction use of antimicrobiotics is responsible for sustaing the tissues and preventing distruction This complex biofilm may now offer some protection from the host’s immunologic mechanisms in the periodontal pocket as well as from antibiotics used for treatment.*  ultrasonic scalers or hand instruments *Mechanical removal of local factors and also disruption of the subgingival plaque biofilm itself. *Anti-infective therapy  ANTI-ENFECTIVE THERAPY 1- *MECHANICAL 2- SISTEMICAL (ORAL ANTIBIOTICS) 3- LOKAL (PLACING ANTI-INFECTIVE AGENTS DIRECTLY INTO THE PERIODONTAL POCKET) NSAID (Offenbacher ve ark., 1987, J Periodontal Res)  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). This immunologic response can be influenced by environmental (e.g., tobacco use), acquired (e.g., systemic disease), and genetic risk factors *Chemotherapeutic agents can modulate the host’s immune response to bacteria and reduce the host’s self-destructive immunologic response. (Reddy ve ark., 2003, Ann Periodontol)  Definitions Anti-infective agents Chemotherapeutic agent that acts by Local reducing the number of bacteria present Anti-infective agent that destroys or Antibiotic inhibits the growth of selective microorganisms, generally at low - SISTEMICAL (ORAL ANTIBIOTICS) concentrations. Chemical antimicrobial agent that can be applied topically or subgingivally to mucous Antiseptic membranes, wounds, or intact dermal surfaces to destroy microorganisms and to inhibit their reproduction or metabolism* antiinfictant angents names of antibiotics names are important *What is the purpose *To reduce the number of bacteria present in the diseased periodontal pocket. 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. advantages of local administrations directly into the pocket The local administration of anti-infective agents, generally directly to the pocket, has the potential to provide greater concentrations directly to the infected area and thus reduce possible systemic side effects*. (American Academy of Periodontology, 2004, J Periodontol) Systemic Administration of Antibiotics *An ideal antibiotic for use in the prevention and treatment of periodontal diseases should be specific for periodontal pathogens, allogenic, nontoxic, substantive, not in general use for the treatment of other diseases, and inexpensive.*  Although oral bacteria are susceptible to many antibiotics, no single antibiotic at the mostly used concentrations achieved in body fluids inhibits all putative periodontal pathogens.  A combination of antibiotics may be necessary to eliminate all putative pathogens from some periodontal pockets.*  *Tetracyclines Tetracyclines have been widely used for the treatment of periodontal diseases. stubborn, resistant periodontitis They have been frequently used to treat refractory* periodontitis. They have the ability to concentrate in the periodontal tissues and to inhibit the growth of Aggregatibacter actinomycetemcomitans. Tetracyclines exert an anticollagenase effect that can inhibit tissue destruction and that may help with bone regeneration. Pharmacology *Bacteriostatic *Gram-positive bacteria > gram-negative bacteria Tetracyclines are effective for the treatment of periodontal diseases in part because their concentration in the gingival crevice is 2 to 10 times that found in serum.* Tetracycline, minocycline, and doxycycline are semisynthetic members of the tetracycline group that have been used in periodontal therapy.  SIDE EFFECTS Gastrointestinal Disturbances Photosensitivity Hypersensitivity Increased Blood Urea Nitrogen Levels Blood Dyscrasias* Dizziness, and Headache *Tooth discoloration occurs when this drug is administered to children who are 12 years old or younger. Tooth discoloration there is bacteria release of beta lactamases enzyme which destroy the amoxicillin, Thus the calvulanic acid which destroy the bacteria that releases the beta-lactamases enzymes *Tetracyclines Metronidazole + amoxicillin–clavulanic acid Although tetracyclines were often used in the past as anti- localised aggresive periodontitis- affects molars specifically 1st molars infective agents, especially for LAP and other types of aggressive periodontitis, they are now frequently replaced by more effective combination antibiotics.  Metronidazole *Nitroimidazole *Bactericidal to anaerobic organisms affective for anaerobic gram negative bacteria 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.  Metronidazole has been used successfully to treat necrotizing gingivitis.* *Single dose of metronidazole (250 mg orally) appears in both serum and GCF in sufficient quantities to inhibit a wide range of suspected periodontal pathogens.  SIDE EFFECTS Antabuse* effect with alcohol intensive septoms like hard fatigue and severe vomiting Inhibits warfarin metabolism (prolongs prothrombin time)* *Avoided in patients who are taking lithium *Metallic taste  Penicillins  Most widely used antibiotics  *Bactericidal  Broad spectrum  SIDE EFFECTS Penicillins may induce allergic reactions and bacterial resistance; up to 10% of patients may be allergic to penicillin.  AMOXICILLIN *Semi-synthetic penicillin Gram + Gram - Susceptible to penicillinase *LAP and GAP *3x1 500 mg (8 days)  AMOXICILLIN - CLAVULANATE POTASSIUM *Resistant to penicillinase enzymes *LAP ve Refractory Periodontitis  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. if the refractory treatment of tetracyline did not work—> then the clindamycin is used  SIDE EFFECTS Pseudomembranous colitis Diarrhea and cramping  Macrolides  Macrolides can be bacteriostatic or bactericidal, depending on the concentration of the drug and the nature of the microorganism  *Erythromycin, spiramycin, and azithromycin.  Erythromycin does not concentrate in GCF, and it is not effective against most putative periodontal pathogens.  For these reasons, erythromycin is not recommended as an adjunct to periodontal therapy.  Spiramycin is active against gram-positive organisms; it is excreted in high concentrations in saliva.  Spiramycin has a minimal effect on increasing attachment levels.  affective against  *Azithromycin -anaerobes and gram-negative bacilli.  *Periodontal lesions > normal gingiva  *Effective for increasing attachment levels in patients with aggressive periodontitis, reducing the degree of gingival enlargement  Currently, the literature presents conflicting reports regarding the efficacy of this antibiotic as an adjunct to periodontal therapy. Serial and Combination Antibiotic Therapy *No single antibiotic is effective against all putative pathogens These “mixed” infections can include a variety of aerobic, microaerophilic, and anaerobic bacteria, which may be both gram negative and gram positive. complex In these cases, it may be necessary to use more than one antibiotic, either serially or in combination  *Metronidazole–Amoxicillin Metronidazole–Amoxicillin with clavulanate LAP (Augmentin) These drugs have an additive effect that involves the suppression of A. actinomycetemcomitans. The metronidazole–ciprofloxacin combination is effective against A. actinomycetemcomitans. Systemic antibiotic therapy + mechanical therapy is valuable for the treatment of recalcitrant periodontal infections and LAP infections that involve A. actinomycetemcomitans. *Currently there is no one microbe or group of microbes that has been demonstrated to be the cause of these diseases. *Antibiotics have had only a modest effect on the management of periodontal diseases.  Debridement of root surfaces, optimal oral hygiene, and frequent periodontal maintenance therapy are important parts of comprehensive periodontal therapy.  An antibiotic strength that is 500 times greater than the systemic therapeutic dose may be required to be effective against biofilms.  It is therefore important to disrupt this biofilm physically so that the antibiotic agents can have access to the periodontal pathogens. AHA SCIENTIFIC STATEMENT mostly used  Local Delivery Agents Supplementary Locally delivered antimicrobial agents are available as adjuncts to scaling and root planing and as aids for the control of growth of bacteria. *Probing depths of more than 5 mm with inflammation are still present after conventional therapy contraindication *If multiple sites are present in the same quadrant, therapy other than locally delivered agents should be considered.  *Subgingival Chlorhexidine Release of chlorhexidine into GCF for 7-10 days A resorbable delivery system has been tested for the subgingival placement of chlorhexidine gluconate with positive clinical results. PerioChip  *Small chip (4.0 mm × 5.0 mm × 0.35 mm) Biodegradable *Release of chlorhexidine into GCF for 7-10 days Adverse effects were minimal  Tetracycline-Containing Fibers (Actisite) *Well tolerated by the oral tissues For 10 days, it sustained tetracycline concentrations which was well beyond the required to inhibit the growth of the pathogens that had been isolated from periodontal pockets. *Reduced probing depth, bleeding with probing with or without scaling and root planing *No longer commercially available  Subgingival Doxycycline A gel system involving the use of a syringe with 10% doxycycline(Atridox) treatment of periodontitis by reducing *Bleeding on probing, Probing Depth Release of doxycylicline into GCF for 7 days  Subgingival Minocycline (Arestin) *2% minocycline *CAL decrease  Subgingival Metronidazole (Elyzol) Provides significant benefits at the level of clinical improvement when applied inside the pocket.. ADVANTAGES Local application increases the antibiotic concentration in the environment and reduces total dosage and systemic side effect. Unlike subgingival irrigation, local agents can maintain the antimicrobial effect for a longer time  *WHEN? Patient’s medical and dental history Patient’s preferences Potential benefits THANK YOU