Local and systemic antimicrobials in the management of inflammatory periodontal diseases Flashcards
To review the principles of the treatment of periodontal diseases · To describe the indications and evidence for using systemic antimicrobials in the management of periodontal diseases · To describe the indications and evidence for using locally applied antimicrobials in the management of periodontal diseases
Principles of treatment
Mechanical plaque control
- pt performed
- non-surgical root surface cleaning
- surgical root surface cleaning (flap)
The role of other factors
Smoking
Stress
Systemic medication and disease
The role of systemic antimicrobials as an adjunct to mechanical treatment in:
Aggressive forms of perio Necrotising forms of perio (NUG, NUP) Periodontal abscess? Deep perio pockets not responding to RSD Progressive or active disease Guided tissue regeneration Not usually chronic (adult) perio
Choice of antimicrobials for systemic use
Tetracyclines (historical)
Metronidazole
Combinations of metronidazole and amoxicillin
Azithromycin
Antimicrobials for aggressive periodontitis
Metronidazole (400mg) and amoxicillin (500mg) both TDS, 7 days
Azithromycin 500mg daily for 3 days
Antimicrobials for aggressive periodontitis - formerly
Tetracycline 500mg TDS, 3 weeks or
Doxycline 100mg daily, 3 week: start 24 hours prior to RP or
Tetracycline 250mg QDS, 2 to 3 weeks
Antimicrobials for deep periodontal pockets not responding to RDS, progressive or active disease
Amoxicillin/ metronidazole combination
Azithromycin
Antibiotic sensitivity testing
Antimicrobials for periodontal abscess
As an adjunct to mechanical treatment (in some circumstances):
- metronidazole
- amoxicillin/ clavulanic acid
- azithromycin
- tetracycline
A warning about azithromycin
Can prolong QTc interval -also an effect of some other drugs - > risk of abnormal heart rhythm Interaction with statins Other interactions Must check BNF/ check with pharmacist or GP if in doubt
Problems evaluating systemic antibiotics
Prospective, randomized placebo-controlled double blind trial ideal
Majority of older studies fall short
Evidence base emerging following more recent studies
Systemic antimicrobials: evidence base 1
Systematic review (Herrera et al. 2002)
-additional benefit (CAL/ probing pocket depth) - deep pockets
< risk of further clinical attachment loss
-progressive or “active” disease
Aggressive disease - might have adjunctive benefit
Amoxicillin and metronidazole combination
When should systemic antibiotics be used? What evidence base?
Commence at completion of RSD, which should be completed within one week
Herrera et al. 2008 - evidence base 1
Systemic antimicrobial evidence base 2: amoxicillin and metronidazole
Improves clinical outcomes in aggressive periodontitis
Systemic antimicrobial evidence base 2: azithromycin
Improved outcomes in chronic periodontitis in deep pockets
As effective as amoxicillin/ clavulanic acid for periodontal abscesses
Improved clinical outcomes in aggressive perio compared with placebo in controlled randomized double blind trial
Advantages of systemic antimicrobials
Useful for aggressive/ active/ progressing sites (pus formation)
Multiple sites
Low cost
Less clinical time
Disadvantages of systemic antimicrobials
Dependent on pt compliance
Unwanted side effects
Can produce microbial resistance to antimicrobials
Can lead to sensitivities and allergies
Locally applied antimicrobials
Metronidazole (Elyzol)
Chlorhexidine (PerioChip) (Chlosite gel)
Minocycline (Dentomycin) - no longer available in UK
Doxycycline (Atridox) - no longer available in UK
Indications for locally applied antimicrobials
Few sites
Poor response to debridement
Deep sites in maintenance pts
Repeat applications?
What is metronidazole 25% (Elyzol)
Semi-solid suspension gel (25% metronidazole)
Forms “liquid crystals” on contact with water
Water in matrix dissolves metronidazole - diffuses into surroundings
Stable for 3 years < 25 degrees C
How to use metronidazole (Elyzol)
Subgingival debridement first
Syringe into pocket until over flowing - wipe off excess
Reapply one week later
Does metronidazole gel (Elyzol) work?
Effective antimicrobial conc. < 1 day
Substantial amount swallowed
< pocket depth and bleeding on probing : residual pockets??
May enhance effects of scaling and root planing
Not for treatment of refractory/ aggressive perio, perio in pts with predisposing illness, those under medical treatment, grade III furcations
Metronidazole (Elyzol) preferred use
As an adjunct:
- slowly progressing perio
- grade II furcations
- angular bony defects
Contra-indications of metronidazole (Elyzol)
Pts allergic to sesame seeds and other precautions
What is PerioChip
Chlorhexidine digluconate 2.5mg in gelatine
Minimum depth >5mm
Biodegrades releasing chlorhexidine over 7-10 days
Does PerioChip work?
Enhanced effects of scaling and root planing especially deep sites
Gain in bone noted and / or no loss, whereas 25% showed bone loss with SRP alone
Chlosite (Ghimas)
Xanthan gel and chlorhexidine (0.5% as digluconate and 1.0% dihydrochloride)
Minocycline 2% (Dentomycin) use
Moderate to severe chronic perio
Adjunct to RSD of sites >/5mm in depth
Not to be repeated within 6 months
Does dentomycin work?
Conflicting results
Various application recommendations
What is doxyclcine 8.5% (Atridox)
Gel that solidifies in minutes Does not flush out Substained release 7-10 days Absorbed and does not require removal Effective against perio pathogens
Does atridox work?
Enhanced effects of RSD
Works in smokers
Suggested use for non-responding site
No longer available in UK
Advantages of locally applied antimicrobials
High local conc of antimicrobial with minimum unwanted side effects
Less reliance on pt compliance
Useful for isolated sites
Disadvantages of locally applied antimicrobials
More expensive
Effective?
Do locally antimicrobials work?
Huge variation in studies
Additional improvement in probing and clinical attachment (mean < 1mm) v RSD alone
> no. sites with PPD reductions >/2mm
Predictability?
Adjunctive in deep or recurrent sites, but not for management of local aggressive perio
Comparison between locally applied antimicrobials
Atridox: > benefits in clinical outcomes and fewest deteriorating sites
-but not great deal of difference
