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Periodontology (IODC) > Local and systemic antimicrobials in the management of inflammatory periodontal diseases > Flashcards

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

1
Q

Principles of treatment

A

Mechanical plaque control

  • pt performed
  • non-surgical root surface cleaning
  • surgical root surface cleaning (flap)
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2
Q

The role of other factors

A

Smoking
Stress
Systemic medication and disease

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3
Q

The role of systemic antimicrobials as an adjunct to mechanical treatment in:

A 
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
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4
Q

Choice of antimicrobials for systemic use

A

Tetracyclines (historical)
Metronidazole
Combinations of metronidazole and amoxicillin
Azithromycin

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5
Q

Antimicrobials for aggressive periodontitis

A

Metronidazole (400mg) and amoxicillin (500mg) both TDS, 7 days
Azithromycin 500mg daily for 3 days

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6
Q

Antimicrobials for aggressive periodontitis - formerly

A

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

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7
Q

Antimicrobials for deep periodontal pockets not responding to RDS, progressive or active disease

A

Amoxicillin/ metronidazole combination
Azithromycin
Antibiotic sensitivity testing

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8
Q

Antimicrobials for periodontal abscess

A

As an adjunct to mechanical treatment (in some circumstances):

  • metronidazole
  • amoxicillin/ clavulanic acid
  • azithromycin
  • tetracycline
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9
Q

A warning about azithromycin

A 
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
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10
Q

Problems evaluating systemic antibiotics

A

Prospective, randomized placebo-controlled double blind trial ideal
Majority of older studies fall short
Evidence base emerging following more recent studies

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11
Q

Systemic antimicrobials: evidence base 1

A

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

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12
Q

When should systemic antibiotics be used? What evidence base?

A

Commence at completion of RSD, which should be completed within one week
Herrera et al. 2008 - evidence base 1

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13
Q

Systemic antimicrobial evidence base 2: amoxicillin and metronidazole

A

Improves clinical outcomes in aggressive periodontitis

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14
Q

Systemic antimicrobial evidence base 2: azithromycin

A

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

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15
Q

Advantages of systemic antimicrobials

A

Useful for aggressive/ active/ progressing sites (pus formation)
Multiple sites
Low cost
Less clinical time

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16
Q

Disadvantages of systemic antimicrobials

A

Dependent on pt compliance
Unwanted side effects
Can produce microbial resistance to antimicrobials
Can lead to sensitivities and allergies

17
Q

Locally applied antimicrobials

A

Metronidazole (Elyzol)
Chlorhexidine (PerioChip) (Chlosite gel)
Minocycline (Dentomycin) - no longer available in UK
Doxycycline (Atridox) - no longer available in UK

18
Q

Indications for locally applied antimicrobials

A

Few sites
Poor response to debridement
Deep sites in maintenance pts
Repeat applications?

19
Q

What is metronidazole 25% (Elyzol)

A

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

20
Q

How to use metronidazole (Elyzol)

A

Subgingival debridement first
Syringe into pocket until over flowing - wipe off excess
Reapply one week later

21
Q

Does metronidazole gel (Elyzol) work?

A

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

22
Q

Metronidazole (Elyzol) preferred use

A

As an adjunct:

  • slowly progressing perio
  • grade II furcations
  • angular bony defects
23
Q

Contra-indications of metronidazole (Elyzol)

A

Pts allergic to sesame seeds and other precautions

24
Q

What is PerioChip

A

Chlorhexidine digluconate 2.5mg in gelatine
Minimum depth >5mm
Biodegrades releasing chlorhexidine over 7-10 days

25
Q

Does PerioChip work?

A

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

26
Q

Chlosite (Ghimas)

A

Xanthan gel and chlorhexidine (0.5% as digluconate and 1.0% dihydrochloride)

27
Q

Minocycline 2% (Dentomycin) use

A

Moderate to severe chronic perio
Adjunct to RSD of sites >/5mm in depth
Not to be repeated within 6 months

28
Q

Does dentomycin work?

A

Conflicting results

Various application recommendations

29
Q

What is doxyclcine 8.5% (Atridox)

A 
Gel that solidifies in minutes
Does not flush out
Substained release 7-10 days
Absorbed and does not require removal
Effective against perio pathogens
30
Q

Does atridox work?

A

Enhanced effects of RSD
Works in smokers
Suggested use for non-responding site
No longer available in UK

31
Q

Advantages of locally applied antimicrobials

A

High local conc of antimicrobial with minimum unwanted side effects
Less reliance on pt compliance
Useful for isolated sites

32
Q

Disadvantages of locally applied antimicrobials

A

More expensive

Effective?

33
Q

Do locally antimicrobials work?

A

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

34
Q

Comparison between locally applied antimicrobials

A

Atridox: > benefits in clinical outcomes and fewest deteriorating sites
-but not great deal of difference

Periodontology (IODC) (3 decks)

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