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Perio lecture 8
What is non-acute periodontitis?
Does not require immediate treatment
Chronic, even aggressive periodontitis,
What are the goals of antimicrobial therapy?
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?
Refractory periodontitis (continued perio attachment loss after treatment)
Systemic antibiotic limitations
Gingival inflammation from supragingival plaque
Diluted thousand-fold before reaching site
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.
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)
Against refractory and aggressive periodontitis
What are the drug interactions of tetracycline?
Calcium, iron, magnesium
Contra-indications of tetracycline
Pregnancy and children <8
What should be the first response against chronic periodontitis?
Scaling and root planing
pocket depth reduction
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
first molar and incisors
Interproximal bone loss on at least
2 permanent teeth
Use short term systemic antibiotics
Which microbes are associated with Local aggressive periodontitis?
What is refractory periodontitis?
progresses despite conventional therapy
As 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?
: should be treated
: used as adjunct
: may improve antimicrobial conditions
When do we use local antimicrobial?
In conjunction with mechanical debridement
What are some advantages of locally delivered agents?
Increased local concentration
Substantivity (remains longer)
Reduced systemic effects
What are the two types of locally delivered agents?
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?
Hardens in the pockets
Controlled release over 7 days
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
Resistance 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?
: 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
Which areas do topical agents not effectively reach?
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?
: has a pocket, shows furcation radiolucency, vital pulp
: 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
Systemic antibiotic therapy
What makes up the largest portion of Orofacial abscesses?
Almost 100% polymicrobial
Almost all include
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
What are the 3 most common microorganisms in periodontal abscesses
How do you manage an acute periodontal abscess?
Drainage and incision
Indications for antibiotic therapy of periodontal abscesses
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
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