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SP 16 - Perio Exam 1 > Role of Antibiotics in Periodontal Therapy > Flashcards

Role of Antibiotics in Periodontal Therapy Flashcards

1
Q

What are indications for Systemic Antibiotic Therapy

A 
Aggressive Periodontitis
Failing Implants
Periodontal abscess (sometimes)
NUG (sometimes)
Recurrent periodontitis
Chronic periodontitis
Poor general response to initial therapy
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2
Q

When do you use systemic antibiotics to treat aggressive periodontitis?

A

Always

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3
Q

Why do we use systemic antibiotics to treat failing implants?

A

We can’t do an SRP on them, and they’re hard to disinfect, so antibiotics can help eliminate an infection

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4
Q

When do we use systemic antibiotics when treating Periodontal Abscesses and/or NUG?

A

If the infection is growing, and patient has fever, malaise, swollen lymph nodes, etc
About 50% of the time
We use them in conjunction with typical periodontal treatments

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5
Q

When do we use systemic antibiotics with chronic periodontitis?

A

It is limited to cases with multiple deep pockets

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6
Q

What is the rationale for using systemic antibiotics?

A

Some periodontal pathogens are invasive, making them difficult to eliminate via SRP (A. actinomycetemcomitans; P. gingivalis; P. intermedia)
These species will recolonize fairly easily, because after SRP, the pockets have been cleaned and there is a lot less for them to compete with

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7
Q

Why is chronic periodontitis not routinely treated with antibiotics?

A

Root planing eliminates most subgingival bacteria associated with chronic periodontitis
Host defense mechanisms are usually effective
Clinical trials suggest that antibiotics are of greater benefit treating aggressive periodontitis than chronic

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8
Q

Systemic antibiotics are helpful in periodontal therapy if…

A

They distribute to the pockets and its soft tissue wall
They reach inhibitory levels in the pocket
Their levels are maintained for an adequate duration
They penetrate host cells and kill invasive bacteria

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9
Q

What is the pathway for antibiotics to distribute to the periodontal pocket?

A

Release from the capillaries and CT, percolates through the JE and into the gingival crevice

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10
Q

What section of the biofilm do we want antibiotics to target? Why?

A

We want to target bacteria in the middle section of the biofilm
Bacteria in the middle struggle to gain nutrients, so they have lower metabolic rate and proliferation rate

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11
Q

What types of antibiotics are used in periodontal therapy?

A 
Penicillins
Metronidazole
Tetracyclines
Fluroquinolones
Clindamycin
Macrolides
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12
Q

What is the mechanism of Fluoroquinolones

A

Mess up the unwinding of DNA

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13
Q

What is the mechanism of Cindamycin

A

Mess up protein synthesis (50S ribosome)

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14
Q

What is the mechanism of Tetracyclines

A

Mess up protein synthesis (30S ribosome)

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15
Q

What is the mechanism of Penicillins

A

Mess up the cell wall

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16
Q

Penicillin

A

Bactericidal
Inactivated by B-lactamases
Reach effective levels in gingival levels
Don’t inhibit A.a strands
Don’t penetrate epithelial cells very well
Amoxicillin has enhanced tissue penetration and good activity agains gram-
Augmentin is as effective as amoxicillin, and it is resistant to inactivation by B-lactamases

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17
Q

Metronidazole

A

Bactericidal activity against strict anaerobes

Less potent activity against facultative bugs like A.a.

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18
Q

Tetracyclines (minocycline and doxycycline)

A

Bacteriostatic against most periodontal pathogens
Can reach higher levels in gingival fluid than in blood serum
Inhibit collagenase, which mediates collagen breakdown in periodontitis
Actively accumulated by oral epithelial cells, gingival fibroblasts, and PMNs

19
Q

How do Tetracylines reach higher levels in gingival fluid than blood serum?

A

Cells of the gingiva act as a small reservoir and uptake it to capactiy (which is 50-60x higher than ECM)
It is a reversible storage, so when tissue levels of Tetracycline is low, it can get released
Levels can decrease in the blood, but stay fairly constant in GCF because it is stored

20
Q

Fluoroquinolones

A

Bactericidal
Extremely active against A.a, but less active against anaerobic bacteria like P.g.
Reach higher levels in gingival fluid than in blood
Penetrate epithelial cells and phagocytes and can kill invasive bacteria

21
Q

How does Ciprofloxacin work?

A

Enhances PMNs bactericidal ability againt A.a

The effect is most significant when the Bacteria:PMN ratio is high

22
Q

Clindamycin

A

Potent bacteriostatic activity against strict anaerobes
Less effective against facultative pathogens like A.a
Can occasionally induce ulcerative colitis
Often used as an alternative antimicrobial agent in penicillin-allergic patients

23
Q

Macrolides/Erythromycin

A

Not especially effective at concentrations seen in gingival fluid
Weak activity against A.a.
Very few clinical trials in treatment of periodontitis

24
Q

Azithromycin and Clarithromycin

A

Reach high concentrations in tissues
Have good activity against A.a, P.g, and many other gram- anaerobes
Penetrates epithelial cells and kills invasive bacteria - also taken up by PMNs and fibroblasts
Macrolides produce anti-inflammatory effects

25
Q

What directs the anti-inflammatory effects of Macrolides?

A

Decreases the GCF IL-8 and TNF in healthy subjects

26
Q

Why is Clarithromycin better at providing anti-inflammatory effects in inflamed tissues?

A

Clarithromycin levels are higher in gingiva than serum and higher in inflamed gingiva than in healthy tissues

27
Q

What are common features of tetracyclines, ciprofloxacin, azithromycin, and clarithromycin?

A

Levels in GCF are often higher than blood levels
Drugs are actively accumulated by PMNs, gingival fibroblasts, and oral epithelium
Can kill invasive bacteria

28
Q

What happens if you get a higher concentration in GCF than the MIC?

A

There’s a good chance the drug will be effective - the reason it may not work is because the MIC is for planktonic bacteria and oral bacteria are in a biofilm

29
Q

What approaches should you take when deciding which antibiotic to use?

A

Use empirical appraoch - based on Randomized clinical trials
Identify pathogens at the site with a molecular technique, then prescribe an antibiotic that will presumably inhibit them
Culture isolated bacteria to identify them and determine their susceptibility to antibiotics

30
Q

What are advantages of molecular tests

A

Plaque or saliva specimens are easy to collect
Sample collection is non-invasive
Tests are specific for A.a.; P.g.; P. intermedia; T. forsythia; T. denticola, F. nucleatum, etc
They’re more sensitive than culture methods
Tests require DNA, not live bacteria

31
Q

What are advantages of Bacterial culturing?

A

Reflects viable bacteria in the pocket
Can assess the predominance of a particular pathogen
Can grow and study unusual bacteria
Can determine antibiotic susceptibility

32
Q

What are the disadvantages of bacterial culturing?

A

Very few periodontal microbiology labs available
Very time consuming and costly
Problems with transport to the lab
Difficult to grow some organisms (spirochetes)
Accuracy dependent on good sampling technique
Not very sensitive

33
Q

How does one best use microbiological tests?

A

Complete initial perio therapy before testing
Assess response to initial therapy - if not responsive, sample the deepest pocket and test for pathogens
Prescribe antimicrobial regimen that is active against pathogens identified by the test

34
Q

Antibiotic regimens for Aggressive and Recurrent Periodontitis

A

1) Amoxicillin (500mg) and Metronidazole (250mg) for 8 days [most common]
2) Azithromycin (500mg) starting dose, then 250mg per day for 4 days [high compliance because just 1 agent taken a day]

35
Q

Limitations of systemic antibiotics in periodontics

A

Antibiotics enhance treatment of aggressive periodontitis more than chronic
To eliminate bacteria in biofilms effectively, antibiotics should be administered after SRP
Antibiotics can have undesirable side effects when given systemically

36
Q

What are some adverse side effects associated with systemic antibiotics

A

Induction of antibiotic resistance
Induction of microbial overgrowth
Hypersensitivity or toxicity

37
Q

What are frequent adverse effects of Penicillins?

A

Rashes
Allergy
Diarrhea

38
Q

What are frequent averse effects of Tetracyclines?

A

Nausea
Diarrhea
Dental staining

39
Q

What are frequent adverse effects of Metronidazole

A

Nausea
Diarrhea
Altered taste
Antabuse effect

40
Q

What are frequent adverse effects of Clindamycin?

A

Rashes
Nausea
Diarrhea

41
Q

What are frequent adverse effects of Azithromucin

A

Diarrhea
Nausea
Cholestatic Jaundice (rare)
Cardiac arrythmia (rare)

42
Q

What are advantages of local delivery of antibiotics?

A

Higher local drug concentrations
Sustained theraputic drug levels (independent of patient compliance)
Effective drug levels can be attained at sites that are difficult to reach
Adverse effects are minimized

43
Q

What are disadvantages of local delivery of antibiotics?

A

Less effective than systemic antibiotics at eradicating invasive bacteria
Can’t eliminate pathogens from the entire oral cavity
Local delivery technique can be time consuming and may not be cost-effective

44
Q

What are current applications of local antibiotic delivery?

A

Treatment of localized recurrent periodontitis in cases that are otherwise stable

SP 16 - Perio Exam 1 (8 decks)

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