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