1. Control of Microorganisms by Antibiotics Weinberg, chapter 11

2. Properties of an Ideal Antibiotic 1.Bacterial specificity 2.Should not produce resistant strains 3.Does not cause allergy or toxicity 4.Does not cause other side effects 5.Does not eliminate normal oral flora 6.Cost effective 7.Hence the ideal has not been found!

3. 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)

4. 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

5. 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)

6. 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

7. Tetracycline Clinical Use: –Refractory periodontitis –Localized aggressive periodontitis –Growing trend to use combination therapies – more effective –Systemic & local delivery systems

8. 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

9. Tetracycline Mechanism of action: –Antibacterial properties: Inhibits growth & multiplication of bacteria Dosage: –250 mg for 2 weeks

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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.

18. 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

19. 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

20. 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

21. Before & AfterTreatment with Metronidazole Probing depth of 6 mm Tissue shrinkage & recession

22. Before & After Treatment with Metronidazole 6 mm probing depthsSurgery has not been required

23. Metronidazole Some evidence of bone gain – client 2.5 years after initial debridement and use of metronidazole

24. 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

25. 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

26. Arestin  Preparing for Arestin Premeasured, premixed, no refrigeration necessary

27. Arestin  Mechanism of action: –Broad spectrum –Bacteriostatic –GCF levels maintained at high levels for at least 14 days

28. 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

29. Arestin  Adverse effects: –Headache –Pain –Mouth ulceration –Slu syndrome –Stomatitis

30. 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

31. Arestin  Clinical efficacy: –27,000 sites treated, n=748

32. 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