Systemic Antimicrobials in Periodontal Therapy 1 (NAIK) Flashcards
Outline the main differences between the 1999 and 2018 periodontal disease classification
- Gingival disease is now split into: gingival health, periodontal health and disease
- Chronic periostitis is now classified as periodontitis and put into stages 1-5 and grades A-C
- Peri implant disease and conditions have been added to the specification
What does it mean when a patient is said to have stage I periodontitis?
The periodontitis is in the initial stages
What does it mean when a patient is said to have stage II periodontitis?
The patient has moderate periodontitis
What does it mean when a patient is said to have stage III periodontitis?
The patient has severe periodontitis with potential for additional tooth loss
What does it mean when a patient is said to have stage IV periodontitis?
The patient has severe periodontitis with potential for loss of dentition
How is periodontitis classified according to the 2018 classifications
- Stage is determined (I-IV)
- Extent and distribution is evaluated
- A grade is given (A-C)
What is the stage at which periodontal disease is at based on?
It is based on severity and complexity of management
How is the extent and distribution of periodontal disease describes?
AS local or generalised
The Molar-Incisor distribution is also considered
What is the grade at which periodontal disease is at based on?
It is based on the evidence or risk of rapid progression
What does it mean when a patient is said to have Grade A periodontitis?
The periodontitis is progressing slowly
What does it mean when a patient is said to have Grade B periodontitis?
The periodontitis is progressing at a moderate rate
What does it mean when a patient is said to have Grade C periodontitis?
The periodontitis is progressing rapidly
What is an infection?
When microorganism invade a host and the host reaction to this invasion
What are antibiotics?
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
What is the nature of periodontal infections?
It is polymicrobial
Name the 3 different plaque hypotheses
- Non specific
- Specific
- Ecological
Which plaque hypothesis is the most accepted?
The ecological plaque hypothesis
How can antibiotics be classified?
- Based on their chemical structures
- Based on their spectrum of activity
- Based on their action
Name some of the groups that antibiotics fall under when they are classified by their chemical structures
- Beta-lactams
- Aminoglycosides
- Sulphonamides
- Tetracyclines
- Azoles
- Quinolones
- Macrolides
Give examples of antibiotics with a beta lactam structure
Penicillin
Give examples of antibiotics with a amino glycoside structure
Gentamycin
Give examples of antibiotics with an azole structure
Metronidazole
Give examples of antibiotics with a quinolone structure
Ciprofloxacin
Give examples of antibiotics with a macrolide structure
Erythromycin, Azithromycin
How do we describe an antibiotics spectrum of activity
- Narrow spectrum
2, Broad spectrum
What does it mean if an antibiotic has a broad spectrum
It affects all (or a lot of) bacterial species
What does it mean if an antibiotic has a narrow spectrum
It only targets certain types of antibiotics
When choosing an antibiotic do we prefer one with a broad or narrow spectrum of activity? why?
Narrow as we don’t want any side effects that may harm the patient
Also we want to minimise the chances of drug resistance bacteria forming
How do we describe the action of antibiotics
- Bacteriostatic
2. Bactericidal
What does it mean if a bacteria is bacteriostatic?
It stops/ inhibit the multiplication of Bactria
What does it mean if a bacteria is bactericidal?
It kills the bacteria
When choosing an antibiotic do we prefer one with that is bacteriostatic or bactericidal? why?
Bactericidal as they work quicker and so patient compliance is higher
List the difference mode of actions of systemic antibiotics
- Inhibits cell wall synthesis
- Inhibits cytoplasmic membran function
- Inhibits nucleic acid synthesis
- Inhibits ribosomal function and hence protein synthesis
- Inhibits folate metabolism
What does systemic mean?
For the whole body it is not specific to one particular site of the host
What is the mode of action of Amoxycillin?
They inhibit cell was synthesis
what is the mode of action of metronidazole
Inhibits nucleic acid synthesis by breaking down strands of DNA
what is the mode of action of tetracyclines and macrolides
Inhibits protein (ribosomal) synthesis
Which type of antibiotics do we commonly prescribed for dental infections
Metronidazole and amoxycillin
What are some of the disadvantages of the use of antibiotics
- Hypersensitivity
- Gastrointestinal disturbances
- Alterations in the commensal flora
- Drug interactions with alcohol
- Bacterial resistance
What is AMR?
Antimicrobial resistance
How many deaths per year in the EU are due to multiple drug resistance bacteria
25,000
Which antibiotic do we avoid in pregnancy?
Tetracycline
What does the antibiotic Guardian teach?
- Don’t demand antibiotics
- Take antibiotics as they are prescribed to use
- Spread the work among friends and relatives
What does antimicrobial stewardship teach?
- Evidence based optimal standards for routine antimicrobial prescribing
- Ensuring competency and education for prescribers
- Communication of issue to all stakeholders
- Auditing the impact and uptake of processes above
- Optimizing outcome for patients prescribed antimicrobials
What is efficacy?
The ability of an antibiotic to produce a desired or intended result
Give some factors that affect the efficacy of antibiotics
- How well the antibiotic can bind to tissue
- Protection of key organisms by non target organisms binding or consuming drugs
- Bacterial tissue invasions
- How extensive the total bacterial load is
- Previous drug therapy
- Non pocket infected sites
- Choice of drug
- Presence of a biofilm
- Beta-lactamasee production can stop beta lactic drugs
what is Beta-lactamase?
An enzyme which can inactivate beta-lactam drugs
Give an example of a Beta-lactamase inhibitor
Clavulanic acid
Why might antimicrobial therapy fail
1. Lack of bacterial culture and sensitivity 2, Failure to achieve drainage 3. Non bacterial causative agent eg viral or fungal infective 4. Incorrect drug duration or dose 5. Defective host responsive 6. Lack of compliance 7. Persistent risk factors like smoking 8. Lack of substantivity of local agents 9. Drug resistance
What is culture ad sensitivity when we talk about antimicrobial therapy?
When we take a sample from the patient and grow the bacterial they have in a lab
Then we test several types of antibiotics on that culture to see which one is the most effective
What is subsubstantivity
The ability of a drug to bind to tissues and please over a period of time
How do we prescribe antibiotics?
- Empirically (ie we prescribe the drug we think will most likely target the bacterial infection)
- Do a culture and sensitivity to see exactly which drug is most effective
What is the ideal way to prescribe antibiotics?
Why can’t we do this in every case?
Doing a culture and sensitivity test
But this is a lengthy and expensive process that is only done when all other antibiotics fail
What is chronic periodontitis?
A patient that has an abundance of deposits of plaque
How do we treat early periodontitis?
Scaling and root surface debridement + OHI
Do we need to prescribe antibiotics for chronic periodontitis?
NO
What is aggressive periodontitis?
When there is an inconsistent match between the presence of local factors and the destruction of oral environment
Which systemic diseases can lead to the manifestation of periodontitis?
Type II diabetes
Do we need to prescribe antibiotics for aggressive periodontitis?
Maybe depending on the cause of periodontitis
Do we need to prescribe antibiotics for periodontitis as a manifestation of systemic disease?
Depends on the systemic disease that can caused the manifestation BUT first we need to distrust the biofilm
Do we need to prescribe antibiotics for necrotising periodontal disease?
YES
Do we need to prescribe antibiotics for abscesses of periodontium?
Theres some evidence to suggest the benefit of prescribing antibiotics in this case but first you must remove the plaque retentive factors and control any other risk actors
When must you prescribe antibiotics to a patient with periodontitis?
When there’s a systemic spread of the disease
How can we tell if theres a systemic spread of periodontitis
- Swelling
- Fever
- Embarrassment of respiratory air way
There is no role for the use of antimicrobials in isolation from m_______ t________
Mechanical therapy such as scaling and RSD
In which stages and grades of periodontitis is the use of antibiotics not indicated?
Stage 3 or 4
Grade A or B
Name some of the possible antibiotic regimens for aggressive periodontitis
- Amoxicillin
- Amoxicillin with clavulanic acid
- Tetracylines
- Minocycline
- Doxycycline
- Ciprofloxacin
- Azithrromycin
- Clindamycin
- Metronidazole
Is Amoxicillin bactericidal or bacteriostatic and which bacteria does it target?
Bactericidal
Targets gram + and -
Is Tetracycline bactericidal or bacteriostatic and which bacteria does it target?
Bacteriostatic
Targets gram + more than gram -
Is minocycline bactericidal or bacteriostatic and which bacteria does it target?
Bacteriostatic
Targets gram + more than gram -
Is doxycycline bactericidal or bacteriostatic and which bacteria does it target?
Bacteriostatic
Targets gram + more than gram -
Is Ciprofloxacin bactericidal or bacteriostatic and which bacteria does it target?
Bactericidal
Targets gram - rods
What are some of the side affects of Amoxicillin
Penicillinase sensitive
What are some of the side affects of Tetracycline
Severe sunburn if exposure to bright sunlight
Severe stomach pain and nausea
What are some of the side affects of Ciprofloxacin
Nausea and gastrointestinal discomfort
What are some of the disadvantages of Minocycline
Bacterial resistance
How is amoxicillin prescribed?
500mg 2-3 times a day for 8 days
How is tetracycline prescribed?
500mg 4 times a day for 21 days
How is minocycline prescribed?
100-200mg once a day for 21 days
How is Doxycycline prescribed?
100-200mg once a day for 21 days
How is Ciprofloxacin prescribed?
500mg 2 times a day for 8 days
Is Clindamycin bactericidal or bacteriostatic and which bacteria does it target?
Bactericidal
Targets anaerobic bacteria
Is Metronidazole bactericidal or bacteriostatic and which bacteria does it target?
Bactericidal
Targets gram -
Is Azithromycin bactericidal or bacteriostatic and which bacteria does it target?
bOTH DEPENDING ON THE DOSE
How is Azithromycin prescribed?
500mg once a day for 4-7 days
How is Clindamycin prescribed?
300mg twice a day for 5-6 days
How is Metronidazole prescribed?
500mg twice a day for 8 days
What are some of the side affects of Azithromycin
Diarrhoea vomiting discomfort
What are some of the side affects of Clindamycin
Diarrhea or colitis
What are some of the side affects of Metronidazole
Dizzy blurred vision
Headaches ineffective for A.actinomycetemcomitans
Go through the guideline for treatment of aggressive periodontitis
- Diagnosis
- OHE
- Do a full mouth supra and sub gingival debridement of pockets greater than 4mm
- Prescribe antibiotics on the FINSL day of debridement
- Review periodontal indices
What are the potential benefits of microbial testing
- May assist in differentiating chronic and aggressive periodontitis
- Can help identify specific bacteria for selection of antibiotic adjuncts
- Performed as part of a risk assessment
What does NUG stand for?
Necrostisin ulcerative gingivitis
What is necrotising ulcerative gingivitis?
It is a mixed bacterial infection caused by a group of anaerobes (spirochaetes and fusiform bacteria )
How do we manage Necrotizing periodontal disease?
- Remove supra and sub gingival deposits
- Prescribe systemic antibiotic (Metronidazole tablets 200mg, three
times daily for 3 days) - Prescribe a Chlorhexidine mouth wash
- Maintenance phase
What questions must we ask ourself when we diagnose a patient with a periodontal abscess?
- Is it vital
- Can drainage be established
- Are there systemic effects (if yes then prescribe systemic antibiotics)
- Can the occlusal force be reduced
When are systemic antibiotics indicated in periodontal therapy?
- Aggressive periodontitis, following the mechanical debridement
- Necrotising periodontal disease
- Acute periodontal abscesses with the evidence of systemic involvement or the spread of infection
- Multiple or recurrent periodontal abscesses in poorly controlled diabetes following thorough debridement
What are some of the non antibacterial effects of tetracycline?
- Concentrated in the GCF
- Binds to the root surface
- Slow release
- Fibroblasts are stimulated
- Osseous induction
- Anticollagenase
