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ADH - Shared Teaching Dental Surgery > Systemic Antimicrobials In Periodontal Therapy > Flashcards

Systemic Antimicrobials In Periodontal Therapy Flashcards

1
Q

What does microbial mean

A

Not just bacteria, but virus, fungus etc

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2
Q

What are antibiotics

A

Drugs that kill or halt the multiplication of bacterial cells at concentrations that are relatively harmless to host tissues and therefore can be used to treat infections caused by bacteria

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3
Q

Bacterial structure

A
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4
Q

Nature of periodontal infections - can you use one single antibiotic to manage it?

A

No, they have multiple causes (different bacteria’s) - Polymicrobial

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5
Q

Plaque hypothesis

A
  • non specific (entire micro flora is responsible for the development of the disease)
  • specific (only certain microorganism are responsible for disease)
  • ecological.. good bacteria, oral probiotics (ecology of bacteria brings about disease, not specifically the bacteria or microorganisms)
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6
Q

Classification of antibiotics - how

A

Based on their clinical structure

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7
Q

Classification of antibiotics based on their spectrum of activity

A

Narrow spectrum

Broad spectrum

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8
Q

Based on the action, antibiotics can be classified as…

A

Bacteriostatic - stops further multiplication of the bacteria

Bactericidal - kills microorganisms / bacteria

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9
Q

Mode of action of systemic antibiotics

A
  1. Inhibition of cell wall synthesis
  2. Inhibition of cytoplasmic membrane function
  3. Inhibition of nuclei acid synthesis
  4. Inhibition of ribosomal function and hence protein synthesis
  5. Inhibition of folate metabolism
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10
Q

What does amoxicillin do

A

Inhibits cell wall synthesis

Belongs to beta lactam penicillin group

Bactericidal

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11
Q

What does metronidazole do

A

Inhibits nuclei acid synthesis by breaking down strands of DNA

Bactericidal

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12
Q

What does tetracyclines and macrolides do

A

Inhibits protein (ribosome) synthesis

Bacteriostatic - they inhibit the multiplication of bacteria

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13
Q

Disadvantages of the use of antibiotics

A
  • hypersensitivity (allergy)
  • gastrointestinal disturbances
  • bacterial resistance
  • alteration sin the commensalism flora eg, oral candida, pseudomembranous colitis
  • drug interactions (eg, alcohol - disulfiram / potential of anticoagulant effect / avpid during pregnancy
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14
Q

Anti microbial resistance - managed by anti microbial stewardship

A

Primary care prescribing alters risk of antibiotic resistance in an individual

  • evidence based optimal standards door rounding anti microbial prescribing (outcome must need clinical needs of pt)
  • ensuring competency and education for prescribers - only when necessary
  • optimising outcome for patients prescribed anti microbials
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15
Q

Antibiotic guardian

A

Supports the uk anti microbial resistance strategy

  • don’t demand antibiotics, take when prescribed
  • take full course otherwise antibiotics will develop resistance
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16
Q

Factors affecting efficacy

A
  • ability of binding of drug to tissue
  • protection of key organisms by non target organisms binding or consuming drug
  • bacterial tissue invasion
  • total bacterial load
  • previous drug therapy
  • non-pocket infected sites
  • choice of bacteriotstaic or bactericides drug
  • presence of biofilm
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17
Q

Factors affecting efficacy - choice of Bactericidal v Bacteriostatic drug

A

Presence of biofilms - must disrupt (intelligent microbial organism network which protects themselves well- microorganism hard to kill unless disrupted hence why periodontal disease management requires mechanical debridement for adjuncts such as antibiotics to be effective)

Beta lactamase production
- some bacteria produces beta-lactase (this will make the antibiotic ineffective) - inactivated beta-lactam drugs eg penicillin

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18
Q

How can we combat ineffectiveness of beta-lactam by beta-lactamase?

A

Clavulanic acid is a beta-lactamase inhibitor sometimes used in combination with amoxicillin to prevent this

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19
Q

Reasons for failure of anti microbial therapy

A
  • lack of culture and sensitivity
  • failure to achieve drainage (of abscess)
  • non bacterial causative agent (eg fungi/virus) antibiotics wont work
  • incorrect drug duration / dose
  • lack of compliance (pt complaisance - correct frequency
  • defective host response
  • persistent risk factors (eg, smoking - interferes with healing)
  • lack of substantivity of local agents (ability f a drug to bind to tissue and release over a period of time)
  • drug resistance
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20
Q

Prescription of antibiotics

A

Empirical

Culture and sensitivity / microbial sensitivity

Mono / combination therapy of antibiotics

21
Q

Ideal investigation -

A

Culture and sensitivity
Polymerase chain reaction
ELISA
Checkerboard hybridisation
Dna analysis via nuceliec acid probes
Genome tests

22
Q
A
23
Q

Indications of systemic antibiotics

A

Gingiva disease - OHI
Chronic periodontis - polymicrobial disease, assess RIsk factors + OHI + manual debridement
Stage 3 / 4, Grade C young pt - antibiotics (refer)
Perio as a manifestation of systemic disease - maybe antibiotics
Necrotising perio disease- antibiotics
Absess of periodontium - maybe antibiotic if systemic environment (raised temp, increase pulse rate etc)
Periodontist associated with endodotic lesions - maybe antibiotics if infections otherwise drain and clean around teeth desired

24
Q

Comparison of local and systemic anti microbial therapy

A
25
Q

Can we replace root surface instrumentation with antibiotics

A

No

Need RSD

26
Q

Can antibiotics be used alone as treatment?

A

No, there is no use of antimicrobials in isolation from mechanical therapy

Biofilms alter minimum inhibitory concentration so RSD/scaling required

27
Q

Why are antibiotics not indicated in the treatment of (chronic) periodontitis (stage 3 or 4 / Grade A or B)

A

Not required because..
- Progression is at a moderate rate
- Pt not young
- evidence of local factors eg plaque / calculus which can explain what is seen clinically

  • inconclusive evidence - hence no antibiotics
28
Q

Antimicrobials as adjuncts to mechanical therapy ? Maybe.. in what situations?

A
  • deep pockets, patients with progressive or active disease or with specific microbiological profiles
29
Q

What type of perio required antibiotics?

A

(Aggressive) periodontitis (stage 3 / 4 .. Grade C)

30
Q

Rationale for systemic therapy

A

Panoral infection in (aggressive) periodontitis
Other oral niches colonised with periodontal pathogens
Drugs are concentrated in GCF
Maintains MIC (minimal inhibitory concentration) for long duration

31
Q

The possible antibiotic regimes for aggressive periodontitis that have been reported in the literature

A

Penicillins (amoxicillin) with/out clavulanic acid
Tetracyclines (doxycycline, tetracycline)
Macrolides (azithromycin)
Nitroimidazole (metronidazole)

Bioavailability of these drugs in GCF is high compared to in serum - hence why these are ideal for treating periodontal diseases

32
Q

Drug choices as adjuncts to mechanical periodontal therapy

A
33
Q

Systemic antibiotic protocol

A
  • check allergies
  • prescribe on last day of debridement
  • complete debridement within 1 week
  • 500mg amoxicillin, 400mg metronidazole
  • TDS, PO, 7 days

Penicillin allergy
- 500mg azithromycin OD, PO, 3 days

34
Q

How to avoid antibiotic resistance associated with aggressive periodontis

A

Microbial testing should be carried out before treatment

35
Q

Microbial test - benefits

A
  • may assist chronic versus aggressive periodontitis diagnosis
  • identify specific bacteria for selection of antibiotic adjuncts
  • performed as part of risk assessment
36
Q

Necrotising periodontal disease signs

A
  • loss of papilla
  • pseudomembrane slur
  • pain
37
Q

Rationale - why do we use systemic antibiotics in necrotising periodontal disease?

A
  • necrotising ulcerative gingivitis (NUG) is a mixed bacterial infection caused by a group of anaerobes - spirochetes and fuse form bacteria (fusospirochaetal complex)
  • theses microorganisms are found in large numbers in the slough and necrotic tissue surface of the ulcer and also invades greatest distance in the underlying intact tissue at the base of the ulcer. This is evident by electron microscopy
38
Q

Management of necrotising periodontal disease

A

Acute phase treatment
1. Removal of supra and sub gingival deposits - ultrasonic scaling
2. Systemic antibiotic - Metronidazole 200mg, 3x daily for 3 days
3. Chlorhexidine mouth rinse

39
Q

Management of periodontal abscess

A

Is it vital?
Can it be drained?

Are there systemic effects? If yes, - systematic antibiotics

Can the occlusal force be reduced?

If potential diabetes involvement - arrange appt with gp for diagnosis

(Systemic effects = fever etc)

40
Q

Why do diabetic pt require antibiotics especially if poorly controlled?

A
41
Q

Other indications for systemic antibiotics?

A

Pericoronitis with he evidence of systemic involvement or spread of infection

Infective endocarditis - consult pt cardiologist

42
Q

Periostat - sub antimicrobial dose doxycycline 20mg

A

Low dose doxycycline 20mg, twice daily
- sub-antimicrobial dose (not antibacterial dose)
- (doxycycline used to kill microorganisms using 100mg dose)
- 20mg dose effective in anti collagenase activity
- collagenase is an enzyme that destroys the connective tissue

Suggested for extended use - at least 3 months as adjunct to scaling & RSD

  • similar prescribing for acne
  • claimed to reduce bystander damage
  • not recommended at present in uk
43
Q

Tetracyclines non-antibacterial effects

A
  • concentrates in GCF
  • binds to root surface
  • slow release
  • fibroblast stimulation
  • osseous induction
  • anticollagenase (inhibits matrix metalloproteinases
44
Q
A
45
Q

Systemic antibiotics are indicated in …

A
46
Q
A
47
Q

Periodontitis is a compilation of..

A

Diseases associated with a complex subgingival flora which can vary in both quantity and quality

48
Q

Summary

A

ADH - Shared Teaching Dental Surgery (8 decks)

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