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