Local and systemic antimicrobials in the management of inflammatory perio disease Flashcards
What are the principles of treatment of periodontal disease?
Mechanical plaque control: Patient preformed Non-surgical root surface cleaning Surgical root surface cleaning Role of other factors: smoking/stress/systemic medication and disease
What are the choice of antimicrobials for systemic use?
Tetracyclines
Metronidazole
Combination of metronidazole and amoxicillin
Azithromycin
What is the choice of treatment with antimicrobials for aggressive periodontitis?
Metronidazole 400mg and amoxicillin 500mg both TDS 7days
Azithromycin 500mg for 3 days
What was the former treatment for aggressive periodontitis?
Tetracycline 500mg TDS 3 weeks
or Doxycycline 100mg daily 100mg daily 3 weeks
or Tetracycline 250mg QDS 2 to 3 weeks
What is the treatment for periodontal abscess?
As an adjunct to mechanical treatment Metronidazole Amoxicillin/clavulanic acid Azithromycin Tetracycline
What warning is there about azithromycin?
Prolong the QTC interval - increasing the risk of abnormal heart rhythm
Interactions include statins
Must check BNF/check with pharmacist or GP
What do you ideally want in a study evaluating systemic antibiotics
Prospective
Randomicsed placebo-controlled,
double-blind trial
When is the role of systemic antimicrobials used as an adjunt to mechanical treatment used?
Aggressive perio NUG/NUP Periodontal abscess Deep periodontal pockets not responding to RSD Progressive or active disease Guided tissue regeneration NOT in chronic adult periodontitis
What are the problems with evaluating systemic antibiotics?
Majority of older adults fall short
Evidence base emerging following recent studies
Systemic antimicrobials, evidence base 1
Herrera et. al 2002 systemic review
Additional benefit (CAL/PPD) - deep pockets
Reduced risk of further progressive or active disease
Aggressive disease might have adjuctive benefit
Amoxicillin and metronidazole combination
Evidence base 2: Herrera et al 2008
Antibiotics should start at the completion of rsd which should be completed within one week
According to evidence, what does amxoicilin and metronidazole improve the clinical outcomes in?
Aggressive periodontitis
According to evidence, what does azithromycin improve outcomes in?
chronic periodontitis in deep pockets
According to evidence, what should be used to treat periodontal abscess?
amoxicillin/clavulanic acid
What are the advantages of using systemic antimicrobials?
Useful for: aggressive/active/progressing sites
Multiple sites
Low cost
Less clinical time
What are the disadvantages of using systemic antimicrobials
Dependent on patient compliance
Unwanted side effects
Can produce microbial resistance to antimicrobials
Can lead to sensitivities and allergens
What are examples of locally applied antimicrobials?
Metronidazole (elyzol)
Chlorhexidine (periochip, chlodite gel)
Minocycline (atridox)
What are indications for locally applied antimicrobials?
Few sites
poor response to debridement
deep sites in maintenance patients
repeat applications
What is metronidazole 25% (elyzol), how does it work?
How long is it stable for?
Semi-solid suspension gel which forms crystals on contact with water
Water in matrix dissolves the metronidazole so can diffuse
3 years at <25 degrees
How do you use Elyzol?
Subgingival debridement first
Syringe into pocket until overflowing
re-apply one week later
Does Elyzol work?
Effective antimicrobial conc <1day Substantial amount in swallows Decrease in BOP and PD's Another study showed P<0.001 in favour of SRP and Elyzol May enhance the effect of SRP
What are indications for using elyzol?
Progressing periodontitis
Grade II furcation’s
angular bony defects
What are contraindications for using elyzol?
refractory or aggressive periodontitis
Periodontitis in pt’s with predisposing illness or under medial treatment
Grade III furcations
Patient’s allergic to sesame seeds
What is the periochip?
Chlorhexidine digluconate 2.5mg in gelatine
What is the minimum depth of periochip?
> 5mm
How does periochip work?
Biodegrades releasing chlorhexidine over 7-10 years
Does the periochip work?
Enhanced effects of SRP (scaling and root planing), especially in deep pockets
Gain in bone and/or no loss compared to 25% bone loss with SRP
What is chlostie (Ghima) made up of?
Xanthan gel and chlorhexidine
0.5% as digluoconate and 1% dihydrochloride
What is Minocycyline 2% (dentomycin) used for?
How is it used?
Moderate to severe chronic periodontitis
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 doxycycline 8.5% atridox? how does it work?
Gel that solidifies in minutes Does not flush out Sustained release 7-10 days Absorbed, doesnt require removal Effective against periodontal pathogens
Does atridox work?
Enhaced effects of RSD
Works in smokers
suggested use in non-responding sites
NO LONGER AVAILABLE IN UK
What are the advantages of locally applied antimicrobials
High local concentration of antimicrobial with minimum unwanted side effects
Less reliance on patient compliance
useful for isolated sites
What are the disadvantages of locally applied antimicrobials?
More expensive
Effectiveness questionable
Do locally applied antimicrobials work?
Huge variation in studies
Additional improvement in probing and clinical attachment (mean<1mm) vs RSD alone
Increased number of sites with PPD reductions of greater than or equal to 2mm
Which ones work best?
Elyzol
Atridox
Periochip
Which locally applied antimicrobials showed the most reduciton in PPD?
tetracycline fibres> doxycycline> minocycline all <1mm
Minimal reductions for chlorhexidine chips and metronidazole
Which local antimicrobial showed the greatest improvement in clinical attachment?
Chlorhexidine/xanthan gel
Metronidazole and chlorhexidine products had no effect
What can the locally applied antimicrobials not be used to treat
Local aggressive periodontitis
