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BDS 3: Periodontics > L2 Antimicrobials in periodontology > Flashcards

L2 Antimicrobials in periodontology Flashcards

1
Q

Which microorganisms are associated with periodontal disease?

A

All gram negative bacteria, mostly anaerobic
- P. gingivalis
- Aggregatibacter actinomycetemcomitans (Facultative)
- Tannerella forsythensis
- Spirochetes of acute NUG
- Prevotella intermedia
- F nucleatum
- T denticola

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2
Q

What would antibiotics in periodontology need to target?

A

Would need abx effective against gram negative, anaerobic microorganisms and spirochetes.

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3
Q

Name the 4 types of antibiotic used in perio.

A
  • Penicillin
  • Nitroimidazoles
  • Macrolides
  • Tetracyclines
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4
Q

Describe the action of penicillins.

A
  • Used for acute infections from gram +ve and -ve bacteria
  • Not effective against aggregatibacter actinomyces
  • Inhibit bacterial cell wall synthesis
  • Most popular choice is amoxicillin
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5
Q

Describe the action of nitroimidazoles.

A
  • E.g. Metronidazole
  • Act by inhibiting DNA synthesis
  • Broad spectrum, act against anaerobic cocci, gram +ve and -ve bacilli
  • Very effective against anaerobes
  • High concentration in GCF (up to twice of serum)
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6
Q

Metronidazole interacts with what drugs?

A
  • Strong interaction with alcohol (pt needs to wait 48 hours after finishing abx to drink)
  • Strong interaction with Warfarin, potentiates effects of Warfarin making pt at high risk of severe bleed
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7
Q

Describe the action of macrolides.

A
  • E.g. Azithromycin
  • Acts by disrupting protein synthesis
  • Conventionally used to treat respiratory tract infections
  • Alternative for pts allergic to penicillin
  • Some benefits in grade C periodontitis and deeper sites
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8
Q

Name 3 tetracyclines.

A
  • Tetracycline
  • Minocycline
  • Doxycycline
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9
Q

Describe the action of tetracyclines.

A
  • Inhibit protein synthesis
  • Effective against gram positive, spirochetes, anaerobic and falcutative bacteria
  • High concentration in GCF
  • Most commonly prescribed antibiotic in perio
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10
Q

When should tetracyclines be avoided?

A
  • Children under 12, pregnant women, breastfeeding women (significant tooth staining)
  • Patients with kidney disease (can exacerbate renal failure)
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11
Q

What substances decrease the absorption of tetracycline?

A
  • Milk
  • Antacids
  • Calcium
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12
Q

Compare doxycycline vs tetracycline.

A
  • Similair efficacy and spectrum
  • Doxycycline concentration in GCF is higher than tetracycline
  • Absorption is less sensitive to presence of food
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13
Q

At what stage of treatment are antimicrobials considered?

A
  • Step 2 therapy
  • For a compliant and engaged patient, good OH, low bleeding
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14
Q

Name some local delivery methods for antimicrobials.

A
  • Mouth rinses and toothpastes (hypothetical)
  • Subgingival irrigation
  • Local delivery of abx
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15
Q

How many times does GCF turn around per hour?

A

GCF turns around 40 times per hour.

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16
Q

What are the 3 principles Goodson suggested for local delivery of antimicrobials in periodontal treatment?

A

Goodson principles 1996:
- The drug needs to be efficient in the periodontal pocket
- The drug concentration needed to be high enough
- Duration of the drug needed to be sufficient

17
Q

What are the advantages of local delivery of antimicrobials?

A
  • Applied directly to target area
  • Higher concentrations achieved directly in the perio pocket
  • Not reliant on pt compliance
  • Reduced systemic side effects
  • Reduced risk of resistance
18
Q

What are the disadvantages of local delivery of antimicrobials?

A
  • Expensive
  • Delivery to the base of the pocket is questionable
  • May result in failure of pocket closure
  • Not active on the mature biofilm (antimicrobials require a clean surface to be effective)
19
Q

Which 2 antimicrobials are used locally and how?

A
  • Minocycline HCl 1mg (preloaded syringes: Dentomycin or Arestin)
  • Chlorhexidine (gelatine discs, PerioChip)
20
Q

Explain how Minocycline HCl 1mg is used and the treatment outcomes.

A
  • Preloaded syringes (Dentomycin or Arestin)
  • Applied every 2 weeks (3 times in total)
  • Broad spectrum antibiotic which suppresses rods and spirochetes
  • Reduces P.gingivalis and Aa
  • 0.4mm clinical gains have been reported
21
Q

Explain how chlorhexidine is used and the treatment outcomes.

A
  • Hydrolysable gelatine disc placed into perio pocket of 5mm or more
  • PerioChip contains 2.5mg chlorhexidine
  • Requires 3 applications over 6 months
  • Pt must avoid ID cleaning for 10 days after placement
  • Maintains GCF concentrations for 7 days
  • £20 per chip
22
Q

What does current evidence suggest regarding the efficacy of local antimicrobials?

A
  • EFP S3 guidance states that locally delivered antibiotics or Chx as an adjunct to subgingival instrumentation in periodontitis pts may be considered
  • Grade 0 recommendation
  • FGDP does not recommend locally delivered antimicrobials due to low quality evidence
23
Q

When are local antimicrobials indicated?

A
  • In isolated pockets which have not responded to conventional non-surgical treatment on several occassions
    +
  • Where there is no detectable calculus at the site and where the pt is maintaining good levels of plaque control
24
Q

What are the advantages and disadvantages of systemic antimicrobial delivery?

A

Advantages:
- Cheaper
- Better evidence

Disadvanatges:
- Systemic side effects
- Increased resistance
- Requires good pt compliance
- Ineffective against mature biofilm
- Concentrations in GCF potentially lower than for local delivery

25
Q

What does current evidence suggest regarding the efficacy of systemic antimicrobials?

A
  • Clinical evidence: abx were found to improve clinical attachment level by 0.4mm, reduce bleeding on probing, increase pocket closure and reduce frequency of residual pockets

EFP S3:
- Not recommended for routine use
- May be considered as an adjunctive therapy in specific cases e.g. generalised stage 3 perio in young pt, severe/progressive perio, uncontrolled diabetes (Grade 0 recommendation)

26
Q

What does EFP S3 level 0 guidance mean?

A

Evidence grade 0 = it is a clinical decision to be made based on each individual case

27
Q

What is Periostat?

A
  • Doxycycline Hyclate 20mg tablet (abx)
  • Sub-antimicrobial dose (SDD)
  • Inhibits action of MMPs (collagenases) to prevent periodontal tissue damage
  • Some evidence to suggest benefits in reducing PPD and CAL
  • POOR evidence, NOT RECOMMENDED by the S3 guidance! May lead to elevations in liver enzymes, concerns over resistance.
28
Q

What is PerioWave?

A
  • An antimicrobial photodynamic therapy
  • Photoactivable solution placed in perio pocket, solution activated by light at specific wavelength
  • Light activation produces cytotoxic free radicals
  • Some evidence to show pocket depth improvement and CA gain short term
  • POOR evidence, NOT RECOMMENDED by the S3 guidance
29
Q

What is the general S3 guidance consensus regarding lasers in periodontics?

A
  • NOT RECOMMENDED
  • Some lasers can remove sub-gingival calculus and exert antimicrobial effects, but the side effects and cost effectiveness are not known. further research required
30
Q

What does the EFP recommend overall regarding adjunctive antibiotics?

A
  • Adjunctive antibiotics are justified in a small number of patients
  • Those with many uncontrolled risk factors (e.g. diabetes) and those who are not responding favourably to other treatment approaches in spite of good compliance
  • The treatment of such patients should be limited to dentists with adequate training in periodontology
31
Q

What does the FGDP recommend overall regarding antimicrobial use in perio?

A
  • Gingivitis: not recommended
  • Necrotising diseases: recommended as an adjunct to local measures where there is evidence of systemic involvement
  • Periodontitis: recommended as an adjunct to OHI, debridement and management of modifiable risk factors in patients aged under 40 with perio stage III or IV and Grade C
32
Q

For patients with necrotising disease and evidence of systemic involvement, what antimicrobial drugs are recommended?

A
33
Q

For patients with stage III/IV grade C periodontitis aged less than 40, what antimicrobial drugs are recommended?

A
  • Complete full mouth RSD in the shortest time possible (7-10 days)
  • At the last visit combine Amoxicillin 500mg and Metronidazole 400mg TDS for 5 days (“Perio Pill”)
  • If allergic to pencillin, prescribe Azithromycin (500mg OD for 3 days) or Doxycycline (100mg BD for first day and then OD for up to 5 days)
34
Q

When are antimicrobials recommended for a periodontal abscess?

A
  • Adjunct to defintive treatment (e.g. drainage, extraction etc.) if there is evidence of systemic spread, pyrexia, lymphadenopathy
  • Amoxicillin or Metronidazole
35
Q

Are antimicrobials recommended for peri-implanitis?

A

Antimicrobials are not recommended as an adjunct to local management of peri-implantitis.

36
Q

Summarise the antibitotics of choice for each periodontal condition.

A

BDS 3: Periodontics (8 decks)

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