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Control of Microorganisms by Antibiotics. Weinberg, chapter 11. Properties of an Ideal Antibiotic. Bacterial specificity Should not produce resistant strains Does not cause allergy or toxicity Does not cause other side effects Does not eliminate normal oral flora Cost effective

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properties of an ideal antibiotic
Properties of an Ideal Antibiotic
  • Bacterial specificity
  • Should not produce resistant strains
  • Does not cause allergy or toxicity
  • Does not cause other side effects
  • Does not eliminate normal oral flora
  • Cost effective
  • Hence the ideal has not been found!
antibiotic adjunctive therapies
Antibiotic Adjunctive Therapies
  • Treatment of aggressive periodontal diseases, chronic periodontitis, refractory periodontitis
    • Initial identification of pathogens
    • Appropriate antibiotic selection
    • Debridement should be carried out first
  • Systemic antibiotics commonly prescribed:
    • tetracyclines, metronidazole
    • amoxicillin, Augmentin, ampicillin
    • ciprofloxacin, clindamycin
    • Periostat (doxycycline)
systemic use concerns
Common side effects:

Nausea, GI upset

Diarrhea

Rash

Resistant bacteria

Poor client compliance

May be to broad spectrum

Common oral manifestations:

Black hairy tongue

Oral candidiasis

Systemic Use – Concerns
controlled release agents
Controlled Release Agents
  • Work by suppressing destructive enzymes produced during inflammatory process or suppressing microbes
  • Considered for localized periodontal sites
  • Systems available include:
    • Actisite (tetracycline fiber)
    • Atridox (doxycycline gel)
    • Arestin (minocycline microsphere)
advantages of controlled release agents
Advantages of Controlled Release Agents
  • Client compliance not an issue
  • GCF concentration greater than serum levels
  • Delivery is localized – reduces systemic effects
  • Reduced side effects
tetracycline
Tetracycline
  • Clinical Use:
    • Refractory periodontitis
    • Localized aggressive periodontitis
    • Growing trend to use combination therapies – more effective
    • Systemic & local delivery systems
tetracycline8
Tetracycline
  • Mechanism of action:
    • Bacteriostatic, broad spectrum
    • More effective against gram-positive bacteria
    • However, A.a. highly susceptible
    • Non-antibacterial properties:
      • Inhibits production & secretion of collagenase
      • Inhibits bone resorption
tetracycline9
Tetracycline
  • Mechanism of action:
    • Antibacterial properties:
      • Inhibits growth & multiplication of bacteria
  • Dosage:
    • 250 mg for 2 weeks
tetracycline side effects
Intrinsic tooth staining

GI upset, abdominal pain

Diarrhea, vomiting

Fungal overgrowth

Resistant bacterial strains

Interferes with bactericidal activity of penicillin\'s & cephalosporins

Reduces effect of BCP

Tetracycline – Side Effects
actisite periodontal fiber
Actisite Periodontal Fiber
  • Clinical use:
    • Pockets measuring  5 mm, bleed on probing
    • Localized treatment for sites that have not responded to previous mechanical therapy
  • How supplied:
    • Cartons of 4 or 10 fibers
    • 23 cm in length
    • 12.7 mg tetracycline hydrochloride
    • Stored at room temperature
actisite
Actisite
  • Application:
    • Treat one quadrant or one side of mouth at a time
    • Client may request anaesthesia
    • Fiber inserted into pocket (circumferential or not)
      • Takes about 10 minutes/tooth
    • Some control of saliva
    • Should contact pocket base
actisite13
Actisite
  • Application:
    • Sealed in place with adhesive
      • Apply in thin even line along gingival margin
      • Surgical dressing not necessary but has been used
    • Removed 7-10 days after placement
      • Curette and/or cotton pliers
      • Fiber comes out in mass or pieces
      • Debride areas as necessary
    • Tissue may appear red following removal
actisite14
Actisite
  • Adverse effects:
    • Discomfort
    • Local erythema
    • Little systemic reaction
    • Used with caution in client with history of candidiasis
    • Application around 12+ teeth may result in oral candidiasis
actisite15
Actisite
  • Client instructions:
    • Avoid brushing & flossing
    • Use antimicrobial rinse
      • Use of CHX may have syngerstic effect
    • Avoid hard or crunch foods, stick foods, chewing gum
actisite16
Actisite
  • Clinical Efficacy:
    • Reduction in bleeding on probing and pocket depth
      • More significant reductions in deeper pockets
    • Reduction in periodontal pathogens
    • Effects of fiber on bone loss, tooth mobility or tooth loss not established
metronidazole
Metronidazole
  • Clinical use:
    • Refractory periodontitis (when combined with amoxicillin or Augmentin)
    • Necrotizing ulcerative gingivitis
    • Moderate – severe periodontitis
    • Aggressive periodontitis (LAP) when combined with amoxicillin or Augmentin
    • Following perio surgery if barrier membranes in place – suppresses P.g.
metronidazole18
Metronidazole
  • Mechanism of action:
    • Bactericidal antimicrobial
    • Disrupts DNA synthesis leading to cell death
    • Selectively kills bacterial associated with periodontal disease
    • Susceptible bacteria include:
      • Fusobacterium, Bacteroides
      • Peptostreptococcus
      • Treponema, Campylobacter
      • Veillonella
metronidazole side effects
GI disturbances

Headache

Dry mouth

Candida infections

Metallic taste

Nausea, diarrhea

Stomatitis

Avoid alcohol when taking: acute nausea, headache, vomiting

May decrease effects of BCP

Metronidazole – Side Effects
metronidazole20
Metronidazole
  • Clinical Considerations:
    • GCF concentrations > blood serum levels
    • When combined with oral hygiene & debridement = beneficial effect on periodontitis
      • Periodontal surgery may not be necessary
    • Doxycycline may be substituted for metronidazole
      • If client can’t abstain from alcohol
metronidazole23
Metronidazole
  • Some evidence of bone gain – client 2.5 years after initial debridement and use of metronidazole
metronidazole24
Metronidazole
  • Dosage:
    • 250 mg tid for 7-10 days
    • 500 mg bid for 1-2 weeks
  • Doxycycline
    • 100 mg per day or BID
  • Metronidazole and amoxicillin or Augmentin
    • 250 mg (of each) TID for 7-10 days
arestin
Arestin
  • Clinical use:
    • Periodontitis with pockets  5 mm
  • How supplied:
    • Box containing 2 trays each containing 12 cartridges
    • Cartridge contains 1 mg of minocycline (semisynthetic tetracycline derivative) microencapsulated in Poly dry powder
    • Cartridge inserted into a cartridge handle
arestin26
Arestin 
  • Preparing for Arestin

Premeasured, premixed, no refrigeration necessary

arestin27
Arestin 
  • Mechanism of action:
    • Broad spectrum
    • Bacteriostatic
    • GCF levels maintained at high levels for at least 14 days
arestin28
Arestin 
  • Application:
    • Insert tip to base of periodontal pocket
    • Expel powder into pocket
    • Bioadhesive microspheres activate & adhere on contact with moisture
    • Cartridge contains enough Arestin for one periodontal pocket
    • Clinical trials: 30 sites treated in less than 10 minutes
    • Dressings or adhesives not required
arestin29
Arestin 
  • Adverse effects:
    • Headache
    • Pain
    • Mouth ulceration
    • Slu syndrome
    • Stomatitis
arestin30
Arestin 
  • Client instructions:
    • Do not eat hard or sticky foods for 1 week
    • Postpone brushing for 12 hours
    • Do not use interproximal cleaning aids for 10 days
arestin31
Arestin 
  • Clinical efficacy:
    • 27,000 sites treated, n=748
arestin32
Arestin 
  • Clinical efficacy:
    • Arestin with debridement demonstrated 27% greater pocket reduction in molars compared to debridement alone
      • Mean reduction of 2 mm (pockets 7 mm +)
    • Effective in furcations
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