Local and Systemic Antimicrobials in the Management of Inflammatory Periodontal Diseases

Question 1

Principles of treatment

Mechanical - types

Role of other factors

Answer 1

Patient performed
Non-Surgical root surface cleaning
Surgical root surface cleaning

Smoking/stress/systemic disease and meds

Question 2

Role of systemic antimicrobials

And what are they used for?

Answer 2

Adjust to mechanical tx
Aggressive forms of periodontitis 
ANUG
Abscesses 
Deep perio pockets not responding to RSD 
Progressive disease

Question 3

Choice of antimicrobials for systemic use

Answer 3

Tetracycline
Metronidazole
Combined amoxicillin and metronidazole
Azithromycin

Question 4

Aggressive periodontitis

Dosage of abs

Answer 4

Metronidazole (400mg) and amoxicillin (500mg0 both TDS for 7 days
Azithromycin 500mg daily for 3 days

Question 5

Periodontal abscesses

Dosage of abs

Answer 5

Adjust to mechanical tx e.g drainage if appropriate
Metronidazole - anaerobic bacteria
Amoxicillin/Azithromycine and tetracycline

Question 6

Caution for azithromycin

Management

Answer 6

Can prolong QT interval –> arrhythmia
Interacts with statin
Other interactions
Check BNF/GP/Pharmacist

Question 7

Problems with evaluating systemic antibiotics

Answer 7

Placebo controlled double blind
Most old studies failed
Systemic antibiotic use should commence at completion of RSD - within one week

Question 8

Amoxicillin and metronidazole

Answer 8

Good for aggressive conditions

Vertical replication - need to be dealt with fast

Question 9

Advantages of systemic antimicrobials

Answer 9

Useful for aggressive/active/progressing sites
Multiple available
Less clinic time
Low cost

Question 10

Disadvantages of systemic antimicrobials

Answer 10

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

Question 11

Locally applied antimicrobials

Answer 11

Metronidazole

Chlorhexidine as perio chip

Question 12

Indications for local applied antimicrobials

Mechanism

Answer 12

Minimal sites
Poor response to RSD 
Deep sites in maintenance patients 
Repeated appts
CHX perio chip inserted into deep pocket

Question 13

Metronidazole 25% Elyzol

How to use

Does it work? Stability?

NOT FOR

Answer 13

Semi solid suspension gel
Forms liquid crystals on contact with water
Water dissolves metronidazole –> diffusion
Sub gingival debridement first - syringe into pocket until overflows and wipe of excess
Reapply 1/52 later

3 years stability
May enhance effect of RSD
Use as adjunct - slowly progressive perio, grade II furcations, angular bony defects

Refractory/aggressive perio
Perio in patients with predisposing illness
Grade III furcations
Sesame seed allergy

Question 14

Perio chip types - 2

Efficacy

Answer 14

CHX digluconate 2.5mg in gelatine - min depth 5mm
Biodegrades and releases CHX over 7-10 days
OR

Chlosite - xanthan gel and CHx

Enhances effects of SRP especially deep sites
Gain in bone or less loss noted

Question 15

Use of dentomycin

Answer 15

Moderate to severe chronic periodontitis
Adjunct to RSD >5mm
Not to be repeated before 6/12

Conflicting results
Various applications recommended

Question 16

Doxycycline
Form

Does it work

Answer 16

Gel which solidifies in mins
Doesn't flush out 
Sustained release 7-10 days 
Absorbed and does not require removal 
Periodontal pathogens

Enhanced effect of RSD
Smokers
Suggested for non responding sites
No longer available in UK

Question 17

Advantages and disadvantages of locally applied antimicrobials

Answer 17

High local concentration with minimum unwanted side effects
Less reliant on patient compliance
Useful for isolated sites
Expensive

Question 18

Conclusion

Answer 18

May have adjunctive role in management in certain clinical situations
Systemic may have role in management of aggressive or necrotising perio disease
Systemic may benefit patients with active disease or deep suppurating or bleeding pockets - consider local first
Locally applied antimicrobials may have role in managing isolated residual periodontal pockets in selected situations and may offer small additional benefits as an adjunct to RSD.