1.23 Chemotherapeutics Flashcards
When should systemic antibiotics be used? (When doing SRP for periodontitis)
Loesche & Giordano ‘94
Compared:
* After the first SRP
* After the last SRP
Antibiotics after the last SRP had the most benefit in deep pockets and reduced the need for surgery
* SRP + Abx group: needed surgery on 2.4 teeth/pt
* SRP only group: surgery on 7.1 teeth/pt
When should amoxicillin + metronidazole be used in aggressive periodontitis patients?
Griffiths 2011
Patients from 18-35 years old and PD ≥5mm
Dosage: Amoxicillin 500mg + Metronidazole 500mg. Both 3x/day for 7 days
Findings: Using the antibiotics at the initial therapy had better results than at retreatment. (And antibiotics at any time had better results than no antibiotics)
- Deep pockets (7+mm): abx group had 1mm less PD
- Moderate pockets (4-6mm): abx group had 0.5 mm less PD
Describe the Slots & Rams 1990 article
Slots & Rams 1990
A narrative review discussing antibiotics knowledge of the time.
The authors recommend microbial susceptibility testing whenever doing antibiotics. They also described pros and cons of systemic vs. local antibiotics:
Systemics:
* (+) can reach deeper layers of biofilm since it travels in the blood serum
* (-) lower concentrations at sites compared to local antibiotics
Locals:
* (+) reaches concentrations 100x greater at the site, compared to systemic antibiotics
* (-) reinfection may occur if bacterial reservoirs exist elsewhere in the body.
What are the indications for antibiotic therapy?
- Refractory periodontitis
- Acute periodontal abscesses / infections
- Aggressive periodontitis
- Stage IV periodontitis
- Immunosuppressed patients
- As an adjunct to SRP
How much will CAL improve if you add antibiotics to SRP?
Smiley 2015
SRP with antibiotics:
CAL +0.2 - 0.6
(compared to SRP only)
Does antibiotics with SRP benefit Type 2 Diabetic patients?
Miranda 2014
Yes = specifically, Amoxicillin & Metronidazole.
Better clinical results (CAL, PD, and fewer sites ≥5 mm)
Amoxicillin: 500 mg TID
Metronidazole: 400 mg TID
Both for 14 days
Is there a benefit of prescribing antibiotics in smokers with periodontitis?
Angaji 2010
Evidence is inconclusive; more data is needed.
However, there appears to be an association with antibiotics providing benefit.
Who described the specific plaque hypotheses?
Loesche 1975 - specific bacteria cause disease
Socransky & Haffajee 1998 - analyzed subgingival plaque samples via DNA probes and checkerboard analyses. Certain bacterial “groups” were found = red complex, green complex, orange complex, etc.
Does metronidazole + SRP offer any benefits, compared to SRP alone?
Loesche 1992
Yes: Adding Metronidazole 250 TID for 1 week to SRP will reduce the need for surgery in patients.
* 62% reduction in surgery in metronidazole group (versus 21% reduction in SRP only group)
This was an RCT with 33 total BANA (+) periodontitis patients. Metronidazole was started after last session of SRP.
* Greatest improvement is seen in deep pockets (≥7mm).
What is the best combination of antibiotics for periodontits treatment?
Systematic reviews by Herrera 2002 and Teughels 2006 recommend metronidazole + amoxicillin.
Usually, doses are:
* Metronidazole 250-500mg TID
* Amoxicillin 500mg TID
Teughels 2006: 28 RCTs. Metro + amoxicillin had the greatest success in PD reduction and Pocket closures.
Antibiotics that were examined: 1- Azithromycin 2- Clarithromycin 3- Metronidazole 4-Metronidazole and Amoxicillin (most frequently reported on), others 5-Tetracycline 6-Ornidazole 7-Spiramycin 8-Minocycline 9- Amoxicillin alone.
What is the van Winkelhoff cocktail?
van Winkelhoff 1992
Amoxicillin 500 mg TID for 7 days
+
Metronidazole 250 mg TID for 7 days
This combination is great for reducing Aa bacteria in severe periodontitis patients
McGowan 2018 - recommended a slightly higher dose (400 or 500 mg TID metronidazole)
What study looked at nonsurgical therapy & azithromycin in smokers?
Mascarenhas 2005
Michigan study with Dr. Wang
Compared SRP vs. SRP + azithromycin
Dose: Azithromycin 500mg on the 1st day, followed by 250mg / day for 4 days.
Finding: Adding azithromycin to SRP was beneficial to smokers. (+0.5 mm more CAL in the antibiotic group, compared to SRP only group).
What study looked at surgical therapy & azithromycin in smokers?
Dastoor 2007
Michigan study with Dr. Wang
Compared:
* surgical therapy only
* surgical therapy + 500 mg azithromycin daily for 3 days
Finding: No additional benefit of adding azithromycin to the surgery.
Is there a benefit of adding tetracyclines to SRP?
Ramberg 2001: There was a short-term benefit on CAL gain (in the 1st year), but no changes in PD or BOP.
If you add antibiotics to the Surgical treatment of peri-implantitis, is there a benefit?
This is an area of ongoing research. However:
Carcuac 2016 showed some benefit of abx.
RCT
Each group had surgery of the implant. In addition:
* (Group 1): 750 mg amoxicillin twice daily. Started 3 days prior to surgery and continued for 10 days.
* (Group 2): local chlorhexidine
* (Group 3): only surgery
Findings: Local Chlorhexidine during surgery added no benefit. Antibiotics seemed to add benefit if implants had a modified surface. However, more research is needed.
Does the Chlorhexidine chip (Periochip) offer benefit when added to SRP?
Jeffcoat 1998
Yes, +0.2 mm CAL if adding a Periochip to SRP sites.
Kaner 2007
It is better to use SRP + amoxicillin & metronidazole, compared to SRP + Chlorhexidine chip.
The amox + metro group had significantly better CAL gain, PD reduction, and pocket closure at 6 months.
What is Atridox and is it effective?
Atridox: 10% doxycycline gel that hardens in the pocket.
Garrett 2000
RCT of 141 patients for a 9 month followup: There was no benefit of adding Atridox. Results were the same for SRP only vs. SRP + Atridox.
What is Arestin and is it effective?
Arestin : Minocycline microspheres
Williams 2001
RCT of 748 patients with 9 month followup.
Findings: Arestin + SRP resulted in 22% more PD reduction, compared to the SRP only group).
What is Actisite and is it still available in the United States?
Actisite: Tetracycline fiber; packed into the pocket and sealed with cyanoacrylate adhesive for 10-14 days, then it is removed. It was the first local antibiotic for periodontitis that was FDA approved in the US.
It is no longer available in the US.
When and how would you use sub-antimicrobial dose (SDD) doxycyline?
Caton 2000
Do SRP & Prescribe 20mg SDD for 9 months, discontinue the prescription for 3 months, then continue it again. This can be continued forever.
No antibiotic resistance is noted at these low doses. This is a host immunomodulating dose.
The adjunctive use of SDD + SRP is more effective than SRP only, over 9 months.
Can NSAIDs be prescribed for host immunomodulation in periodontitis?
Williams 1989
Flurbiprofen 50mg BID for 2 years.
There was a significant reduction in bone loss compared to the control group.
(However, this is not commonly done due to possible side effects)
Can changing the diet help cure periodontitis?
Iwasaki 2020
A cross-sectional study (n=1075 patients) examining the Mediterranean diet and periodontitis.
Olive oil (which has Omega 3’s) is somewhat protective in preventing periodontitis.
Can antiresorptive drugs help Diabetics with periodontitis?
Rocha 2001
Diabetics with periodontitis were prescribed either Alendronate 10mg daily, or a placebo.
Results: No real effects on the HbA1c, but the Alendronate group appeared to have better PD (+0.42mm) and more improvement in alveolar bone height than the placebo group.
(However, is a periodontist really going to prescribe Alendronate for periodontitis??)
