Non-surgical periodontal treatment and adjunctive antibiotics Flashcards
What is involved in step 1 of non-surgical periodontal therapy
- Education of periodontal disease process
- Risk factor analysis - plaque, diabetes, smoking cessation, stress
- Motivation and behaviour change - OHI
- Basic mechanical scaling/PMPR of clinical crown
What plaque and bleeding scores would indicate and “engaging patient”
- Plaque Scores < 20%
- Bleeding scores < 30%
- Or plaque/bleeding score improvement of 50%
What should we be removing with non-surgical mechanical therapy
- Plaque (bacteria)
- Calculus (mineralised plaque)
AY BAWS CAN I HABE DE NOTE PLZ
Its practically hard to achieve removal of only plaque and calculus and we often leave behind sub-gingival calculus, PMPR should be atraumatic to soft and hard tissues of the periodontium
What is the difference between step 1 and step 2 perio therapy
Step 1: Supra gingival PMPR
Step 2: Sub-gingival PMPR
What complaints/comments can patients often have after non-surgical therapy
- Gums have shrunk and teeth look longer
- Gaps between teeth are really big now
- Teeth are really sensitive
- Gums bleed less
- Teeth have firmed up
- Teeth are more loose
Consent is vital before treatment to avoid complaints
Describe some features of the healing response of non-surgical periodontal therapy
- Inflammation resolution and pocket depth reduction
- Recession and sensitivity
- Long junctional epithelium attachment may occur
- Repopulation with “healthier” less pathogenic microflora
- Formation of new bone, new CT, new cementum and new attachment can occur but is unpredictable
- Healing of JE takes around 1 week and for CT up to 4 weeks in which time probing should be avoided
- Repair as opposed to regeneration
When should you reassess after non-surgical therapy
3 months
What can be considered a successful non-surgical periodontal therapy
- Improvement plaque scores < 20%
- An increased resistance to periodontal probing
- Absence/reduction of bleeding (<10%)
Clinical End Points: - No BOP
- Pocket closure (PD<4mm.)
What teeth often show the best clinical improvement after initial treatment
Single rooted teeth tend to be better than molars
What improvements can you expect from non-surgical therapy
- Reduction in redness, inflammation and bleeding
- Deep sites respond with greater improvement than shallower pockets
- The greatest rate of healing happens between 3 and 6 weeks after therapy
What is the function of an antiseptic
weakens and slows growth of bacteria
What is the function of an anthelminthic
It works against parasites - worms
What are the 3 mechanisms of bacterial resistance
- Natural - bacteria naturally resistant to certain antibiotics
- Spontaneous - random genetic mutation
- Acquired - one species acquiring resistance from another
What questions should we ask before handing out antimicrobials
Are they absolutely necessary?
Can the infection be manage through mechanical drainage?
What are the side effects of antibiotics
- Stomach upset (nausea and vomiting)
- GI disorder (diarrhoea)
- Headache
- Metallic taste
- General unwellness (irritability/flu)
- Rashes
- Total adverse events
What modes of action can antibiotics work with
- Inhibition of cell wall synthesis
- Inhibitors of protein synthesis
- Inhibitors of nucleic acid synthesis
Name an antibiotic that works by inhibition of cell wall synthesis
- Amoxicillin
Name an antibiotic that works by the inhibition of protein synthesis
- Azithromycin
- Tetracycline/Doxycycline
Name an antibiotic that works by inhibition of nucleic acid synthesis
- Metronidazole
What rationale can there be for the use of adjunctive antimicrobials
- Primary aetiology of periodontitis is bacterial plaque
- Periodontal pathogens can invade connective tissues
- Oral niches of bacteria not reachable by non-surgical mechanical therapy
What are only periodontal disease cases where we should consider prescribing antimicrobials
Acute gingival problems: - necrotising gingivitis/ periodontitis
- Abscesses where local drainage is not possible and there is systemic involvement (fever, lymph nodes swollen etc.)
Certain “forms” of periodontitis:
- Severe, rapidly progressing forms of the disease often correlated with specific forms of bacteria
- Grade C patients
What single agent antibiotics can be prescribed for periodontitis
- Amoxicillin
- Metronidazole
- Doxycycline
- Azithromycin
What dose for Amoxicillin is normally prescribed for periodontitis
500mg TDS
What dose for Metronidazole is normally prescribed for periodontitis
400mg TDS
What dose for Doxycycline is normally prescribed for periodontitis
200mg day 1 and then 100mg/day up to 21 days
What dose for Azithromycin is normally prescribed for periodontitis
100mg once daily for 3 days
What antibiotic combination can be prescribed for periodontitis
Amoxicillin (500mg TDS) + Metronidazole (400mg TDS) for 7 days
What are local antimicrobials
These are antimicrobial medications that are administered or delivered at the site of action - usually straight into the pocket
What are the advantages of using local antimicrobials
- High doses directly on the site of required action
- No risk of systemic side-effects
- Assured compliance
What are the disadvantages of using local antimicrobials
- Doubts regarding substantivity (ability to stay within the target)
- Antibiotic resistance and selection bacteria within the pocket
How does chlorhexidine work
Due to the cationic CHX molecule that is rapidly attracted by -ve charge bacterial surface and causes membrane damage
Why can chlorhexidine have disappointing results when used subgingivally
it has a short lived effect
What are the potential side effects of using chlorhexidine as a local antimicrobial
- Staining - esp. on anterior restorations
- Taste distortion
- Mucosal desquamation and parotid enlargement
What is chlorhexidine’s effect on plaque
Im trine get you to say that it will only prevent plaque and not remove it
AY BAWS CAN I HABE DE NOTE PLZ
Chlorhexidine is not for regular use and not a substitute for mechanical plaque removal
What are the indications for the use of chlorhexidine
- Unable to carry out mechanical plaque control before and following periodontal surgery
- Inter-maxillary fixation (jaw fractures)
- May also help control aphthous ulceration
Name some local antimicrobials
- Doxycycline
- Minocyclin
- Tetracycline fibres
- Metronidazole
(mostly in the form of a gel except the fibres that slowly release tetracycline in the pocket)
What is a periochip and how often might it need to be used
This is a 2.5mg chlorhexidine in gelatin capsule that degrades in 7-10 days
- Bigger reductions seen in deeper pockets (obvs)
- May need to apply every 3 months in maintenance
What are the clinical features of necrotising gingivitis
Necrosis and ulceration of interdental papillae, gingival bleeding, pain, halitosis
What are the clinical features of necrotising periodontitis
Necrosis and ulceration of interdental papillae, gingival bleeding, pain and halitosis but also includes periodontal attachment loss/bone loss and occasionally bone sequestrae
What are some of the main bacteria that are involved in necrotising periodontal diseases
- Spirochetes and fusiform bacteria
- P. intermedia, peptostreptococcus genus associated
What are some of the risk factors of necrotising periodontal diseases
- Malnutrition
- Stress
- Poor oral hygiene
- Smoking/Alcohol
- More common in HIV/AIDS patients
- Compromised immune responses
What are the management options for necrotising periodontal disease
- Initial debridement under LA if possible
- Prescribe chlorhexidine mouthwash
- Consider antibiotics only if spreading infection or systemic involvement
- 400mg Metronidazole 3x daily or Amoxicillin 500mg TDS for 3-5 days
- Recommend analgesia
- Periodontal follow up and prevention
What is a periodontal abscess
Localised accumulation of pus located within the gingival wall of the periodontal pocket and microbiology similar to periodontal microflora
Describe the onset and clinical features of acute periodontal abscesses
- Develops and lasts for a few days or a week
- Sudden onset of pain on biting/throbbing pain
- Gingiva are red, swollen and tender
- Pus and discharge from the gingival crevice
Describe the clinical features of chronic periodontal abscesses
- Longer lasting than acute perio abscesses and develops slowly, pain is usually of low intensity
- Bad taste and discomfort
- Tooth often tender to bite and mobile
- Pus may be present and discharge from the gingival crevice/sinus in the mucosa overlying the affected root
What are the aetiologies of periodontal abscesses
- Untreated/refractory periodontitis, during maintenance and following non-surgical scaling, periodontal surgery (therapy)
- Following systemic antimicrobials or use of calcium channel blockers (medications)
- In a non-periodontitis patient due to; impaction of foreign bodies, harmful chewing habits, orthodontics, gingival enlargement, perforations or root damage
What are the management options for periodontal abscesses
- Focus on removing the source of infection first
- Establish drainage when possible, usually through the pocket
- Mechanical debridement reduces the bacterial load and facilitates wound healing
- Pyrexia, lymph node involvement or facial swelling may occasionally require the use of antibiotics
When should we consider antibiotic regimens for periodontal abscesses
only if local measures fail to control systemic spread
Where can you find the guidelines for antibiotic prescribing
- FGDP
- SDCEP
