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What is non-acute periodontitis?
- Does not require immediate treatment
- Periodontal abscesses require immediate
- Chronic, even aggressive periodontitis, would not
What are the goals of antimicrobial therapy?
- Control plaque
- Kill pathogens
- Enhance healing
- inhibit tissue destruction
- Alternative to surgery
What does the ideal antibiotic do?
- Substantivity- remain in target tissue
- No drug resistance
- Inhibit target organisms
Why are perio diseases difficult?
- Perio diseases are heterogeneous
- Diagnosis based on clinical signs, not microbial pathology
- Microbio assessment is expensive
What do we use for a local periodontal condition?
Deliver a local antibiotic
What are systemic antibiotics?
- For patients not responding to conventional therapy
- An antibiotic prophylaxis
- During acute periodontal infection with systemic presentation
What indications are for systemic antibiotics as an adjunct to mechanical therapy?
- Agressive periodontitis
- Refractory periodontitis (continued perio attachment loss after treatment)
Systemic antibiotic limitations
- Gingival inflammation from supragingival plaque
- Diluted thousand-fold before reaching site
- Bacterial resistance
Commonly used systemic antibiotics
- Bactericidal (cell wall synthesis)
- Not for Penicillin allergic
- With augmentin, inhibits beta-lactamase
When would we use Augmentin?
- Patients with resistance to conventional antibiotics
- Same activity as penicillin
- Useful against Beta-lactamase microorganisms
- Bactericidal (inhibits bacterial DNA synthesis)
- Effective against anaerobic bacteria
- Ineffective against A.a.
- Hepatic disease
- Pregnancy (1st trimester)
- Concurrent alcohol intake
- Interactions with oral anticoagulants (warfarin)
Why use Amoxicillin and Metronidazole together?
- Against aggressive and refractory periodontitis
- Effective against Aa
- Suppression against P. gingivalis
- Bacteriostatic (rapidly multiplying bacteria)
- Inhibit protein synthesis and collagenases
- Against refractory and aggressive periodontitis
What are the drug interactions of tetracycline?
- Calcium, iron, magnesium
- These will inactivate tetracycline
Contra-indications of tetracycline
- Pregnancy and children <8
- Renal disease
What should be the first response against chronic periodontitis?
- Scaling and root planing
- Provides pocket depth reduction and attachment level gain
What should be done if inflammation recurs with a patient that had SRP?
- Surgery as treatment option
- Little indication exists for routine systemic antibiotics
Localized aggressive periodontitis
- Onset around puberty
- localized to first molar and incisors
- Interproximal bone loss on at least 2 permanent teethUse short term systemic antibiotics
Which microbes are associated with Local aggressive periodontitis?
- P. Gingivalis
- E. corrodens
- C. rectus
- F. nucleatum
What is refractory periodontitis?
- Disease that progresses despite conventional therapyAs many as 10-20% experience refractory
- Most often smokers and diabetics
How do you treat refractory periodontitis
- Systemic antibiotics can be used as an adjunct
- Local delivery agents and SRP are ideal for localized
- Culture the pathogens and discover susceptibilities
In which cases do we use systemic antibiotics?
- Chronic Periodontitis: should be treated without
- Refractory periodontitis: used as adjunct
- Aggressive: may improve antimicrobial conditions
When do we use local antimicrobial?
In conjunction with mechanical debridement
What are some advantages of locally delivered agents?
- Lower doses
- Increased local concentration
- Substantivity (remains longer)
- Reduced systemic effects
What are the two types of locally delivered agents?
- non-absorbable: Actisite
- Absorbable: Arestin, Periochip (chlorhexidine)
Tetracycline fiber: Actsite
- Non-absorbable local antibiotic
- Insert the fiber into the pocket, can cause abscess
- Not in the market anymore
Disadvantages for Actsite
- Time required for placement
- Needs removal in 10 days
- In >12 teeth, resulted in candidiasis
What are the 3 absorbable local antibiotics?
- Doxycycline polymer
- Hardens in the pockets
- Controlled release over 7 days
- Minocycline microspheres
- sustained release
- Small biodegradeable film
- Insert film inside the pocket
Which patients may benefit themost from local antimicrobial therapy?
- Maintenance patients with a few non-responding sites
- Local recurrent disease
What is the key to periodontic treatment success?
- Mechanical debridement prior to application of antimicrobial agents
- Mechanical plaque control after periodontal treatment
Why is judicious antibiotic use warranted?
- Antibiotic use is correlated with bacterial resistanceResistance does not have to be requent to be significant
What types of adjunctive periodontal therapy are used in gingivigtis management?
Topical agents: antimicrobial mouthrinses
What types of periodontal therapy are used in the management of periodontitis?
- Systemic agents: antibiotics
- Locally delivered: antibiotics, antimicrobials
Advantages of administered topical antimicrobials
- No upset stomach
- No floral alterations
- Easy patient administration
Disadvantages of patient administered topical antimicrobials
- hard to keep therapeutic levels at the site
- Concentration fluctuates over time
- Requires patient compliance
What are phenolic compounds used for? How? Name a brand
- Effective in redution of plaque and gingivitis
- Denatures proteins and damages cell membranes
What is chlorhexidine gluconate used for?
Treatment of gingival inflammation and bleeding
What advantage does chlorhexidine have over listerine?
- Chlorhexidine stays longer in the tissues
- Agent persists in saliva and released slowly from oral tissues
When is the best tiime to use chlorhexidine?
Right after periodontal surgery
Adverse effects of chlorhexidine use
- Staining of teeth, restorations, tongue
- Dryness of tissues
- Hypersensitivity and allergies
What are the indications for chlorhexidine use?
- Adjunct for supragingival plaque control
- Following periodontal therapy
- Elderly and mentally handicapped patients
Contraindications of chlorhexidine
- History of allergy
- Pregnancy questionable
Which areas do topical agents not effectively reach?
- Subgingival compartments
- They mostly control gingivitis
What are the local signs of acute infections?
What are some systemic signs and symptoms of acute infections?
- Elevated vital signs
How do you differentiate between a periodontal and a pulpal abscess?
- Periodontal: has a pocket, shows furcation radiolucency, vital pulp
- Pulpal: Non-vital pulp, swelling localized to apex w/ a tract
What is the most common dentoalveolar abscess?
- Dental caries with subsequent endo infection
- Involves 3-7 bacterial species or more
- Anaerobic microorganisms predominate
Therapy for dentoalveolar abscess
- Endo therapy
- Systemic antibiotic therapy
What makes up the largest portion of Orofacial abscesses?
- Almost 100% polymicrobial
- Almost all include anaerobic organisms
What is the major cause of tooth loss during periodontal maintenance phase?
Where are periodontal abscesses most likely to occur?
In a pre-existing pocket
Which patients are periodontal abscesses usually found in?
Patients with untreated peridontitis
What is a predisposing condition for periodontal abscesses?
Some clinical findings of periodontal abscesses
- Swelling, erythema, bleeding on probing
- Some mobility
What are the 3 most common microorganisms in periodontal abscesses
- Fusobacterium nucleatumParvimonas microsPrevotella intermedia
How do you manage an acute periodontal abscess?
- Drainage and incision
- Extraction possible
- systemic antibiotics
Indications for antibiotic therapy of periodontal abscesses
- Deep/inaccessible pocket
Which drugs are used for abscesses if amoxicilling (penicillin) allergic?
- Usually partially erupting or impacted mandibular 3rd molars
- Plaque retention, food impaction
- Similar microbes to periodontal abscesses
Treatment of pericoronal infecitons
- Depends on severity
- Systemic complications
- Remove pericoronal flaps
Why remove pericoronal flaps for pericoronal infections?
Remove as a protective measure against acute involvement
Where can untreated pericoronal infections spread?
Into facial spaces
What is the antibiotic of choice for orofacial infections?
- Broad spectrum penicillin compounds
- -augmentin (amoxicillin + potassium clavulanate)
Why are antibiotics alone insufficient?
- Insufficient penetration into abscess area
- Enhanced resistance of bacteria within biofilm
When do you refer an abscess?
- Infection with extensive spreading
- -periorbital, sublingual, submandibular
- Infection not responding to treatment