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2012-12-07 18:49:55

Perio lecture 8
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  1. What is non-acute periodontitis?
    • Does not require immediate treatment
    • Periodontal abscesses require immediate
    • Chronic, even aggressive periodontitis, would not
  2. What are the goals of antimicrobial therapy?
    • Control plaque
    • Kill pathogens
    • Enhance healing
    • inhibit tissue destruction
    • Alternative to surgery
  3. What does the ideal antibiotic do?
    • Substantivity- remain in target tissue
    • No drug resistance
    • Inhibit target organisms
  4. Why are perio diseases difficult?
    • Perio diseases are heterogeneous
    • Diagnosis based on clinical signs, not microbial pathology
    • Microbio assessment is expensive
  5. What do we use for a local periodontal condition?
    Deliver a local antibiotic
  6. What are systemic antibiotics?
    • For patients not responding to conventional therapy
    • An antibiotic prophylaxis
    • During acute periodontal infection with systemic presentation
  7. What indications are for systemic antibiotics as an adjunct to mechanical therapy?
    • Agressive periodontitis
    • Refractory periodontitis (continued perio attachment loss after treatment)
  8. Systemic antibiotic limitations
    • Gingival inflammation from supragingival plaque
    • Diluted thousand-fold before reaching site
    • Bacterial resistance
  9. Commonly used systemic antibiotics
    • Amoxicillin
    • Metronidazonle
    • Azythromycin
    • Tetracycline
  10. Amoxicillin
    • Bactericidal (cell wall synthesis)
    • Not for Penicillin allergic
    • With augmentin, inhibits beta-lactamase
  11. When would we use Augmentin?
    • Patients with resistance to conventional antibiotics
    • Same activity as penicillin
    • Useful against Beta-lactamase microorganisms
  12. Metronidazole Indications
    • Bactericidal (inhibits bacterial DNA synthesis)
    • Effective against anaerobic bacteria
    • Ineffective against A.a.
  13. Metronidazole contraindications
    • Hepatic disease
    • Pregnancy (1st trimester)
    • Concurrent alcohol intake
    • Interactions with oral anticoagulants (warfarin)
  14. Why use Amoxicillin and Metronidazole together?
    • Against aggressive and refractory periodontitis
    • Effective against Aa
    • Suppression against P. gingivalis
  15. Tetracycline characteristics
    • Bacteriostatic (rapidly multiplying bacteria)
    • Inhibit protein synthesis and collagenases
    • Against refractory and aggressive periodontitis
  16. What are the drug interactions of tetracycline?
    • Calcium, iron, magnesium
    • These will inactivate tetracycline
  17. Contra-indications of tetracycline
    • Hypersensitivity
    • Pregnancy and children <8
    • Renal disease
    • Candidiasis
    • Photosensitivity
  18. What should be the first response against chronic periodontitis?
    • Scaling and root planing
    • Provides pocket depth reduction and attachment level gain
  19. What should be done if inflammation recurs with a patient that had SRP?
    • Surgery as treatment option
    • Little indication exists for routine systemic antibiotics
  20. 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
  21. Which microbes are associated with Local aggressive periodontitis?
    • Aa
    • P. Gingivalis
    • E. corrodens
    • C. rectus
    • F. nucleatum
    • Spirochetes
  22. What is refractory periodontitis?
    • Disease that progresses despite conventional therapy
    • As many as 10-20% experience refractory
    • Most often smokers and diabetics
  23. 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
  24. In which cases do we use systemic antibiotics?
    • Chronic Periodontitis: should be treated without
    • Refractory periodontitis: used as adjunct
    • Aggressive: may improve antimicrobial conditions
  25. When do we use local antimicrobial?
    In conjunction with mechanical debridement
  26. What are some advantages of locally delivered agents?
    • Lower doses
    • Increased local concentration
    • Substantivity (remains longer)
    • Reduced systemic effects
  27. What are the two types of locally delivered agents?
    • non-absorbable: Actisite
    • Absorbable: Arestin, Periochip (chlorhexidine)
  28. Tetracycline fiber: Actsite
    • Non-absorbable local antibiotic
    • Insert the fiber into the pocket, can cause abscess
    • Not in the market anymore
  29. Disadvantages for Actsite
    • Time required for placement
    • Needs removal in 10 days
    • In >12 teeth, resulted in candidiasis
  30. What are the 3 absorbable local antibiotics?
    • Atridox
    • Arestin
    • Periochip
  31. Atridox
    • Doxycycline polymer
    • Hardens in the pockets
    • Controlled release over 7 days
  32. Arestin
    • Minocycline microspheres
    • sustained release
  33. Chlorhexidine
    • Periochip
    • Small biodegradeable film
    • Insert film inside the pocket
  34. Which patients may benefit themost from local antimicrobial therapy?
    • Maintenance patients with a few non-responding sites
    • Local recurrent disease
  35. What is the key to periodontic treatment success?
    • Mechanical debridement prior to application of antimicrobial agents
    • Mechanical plaque control after periodontal treatment
  36. Why is judicious antibiotic use warranted?
    • Antibiotic use is correlated with bacterial resistance
    • Resistance does not have to be requent to be significant
  37. What types of adjunctive periodontal therapy are used in gingivigtis management?
    Topical agents: antimicrobial mouthrinses
  38. What types of periodontal therapy are used in the management of periodontitis?
    • Systemic agents: antibiotics
    • Locally delivered: antibiotics, antimicrobials
  39. Advantages of administered topical antimicrobials
    • No upset stomach
    • No floral alterations
    • Easy patient administration
  40. Disadvantages of patient administered topical antimicrobials
    • hard to keep therapeutic levels at the site
    • Concentration fluctuates over time
    • Requires patient compliance
  41. What are phenolic compounds used for? How? Name a brand
    • Effective in redution of plaque and gingivitis
    • Denatures proteins and damages cell membranes
    • Listerine
  42. What is chlorhexidine gluconate used for?
    Treatment of gingival inflammation and bleeding
  43. What advantage does chlorhexidine have over listerine?
    • Chlorhexidine stays longer in the tissues
    • Agent persists in saliva and released slowly from oral tissues
  44. When is the best tiime to use chlorhexidine?
    Right after periodontal surgery
  45. Adverse effects of chlorhexidine use
    • Staining of teeth, restorations, tongue
    • Dryness of tissues
    • Taste
    • Hypersensitivity and allergies
  46. What are the indications for chlorhexidine use?
    • Adjunct for supragingival plaque control
    • Following periodontal therapy
    • Elderly and mentally handicapped patients
  47. Contraindications of chlorhexidine
    • History of allergy
    • Pregnancy questionable
  48. Which areas do topical agents not effectively reach?
    • Subgingival compartments
    • They mostly control gingivitis
  49. What are the local signs of acute infections?
    • Pain
    • Erythema
    • Swelling
    • Purulence
  50. What are some systemic signs and symptoms of acute infections?
    • Lymphadenopathy
    • Fever
    • Malaise
    • Elevated vital signs
  51. 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
  52. What is the most common dentoalveolar abscess?
    • Dental caries with subsequent endo infection
    • Involves 3-7 bacterial species or more
    • Anaerobic microorganisms predominate
  53. Therapy for dentoalveolar abscess
    • Endo therapy
    • Incision/drainage
    • Extraction
    • Systemic antibiotic therapy
  54. What makes up the largest portion of Orofacial abscesses?
    • Almost 100% polymicrobial
    • Almost all include anaerobic organisms
  55. What is the major cause of tooth loss during periodontal maintenance phase?
    Periodontal abscess
  56. Where are periodontal abscesses most likely to occur?
    In a pre-existing pocket
  57. Which patients are periodontal abscesses usually found in?
    Patients with untreated peridontitis
  58. What is a predisposing condition for periodontal abscesses?
    Diabetes Mellitus
  59. Some clinical findings of periodontal abscesses
    • Swelling, erythema, bleeding on probing
    • Some mobility
    • Suppuration
    • Pain
  60. What are the 3 most common microorganisms in periodontal abscesses
    • Fusobacterium nucleatum
    • Parvimonas micros
    • Prevotella intermedia
  61. How do you manage an acute periodontal abscess?
    • Drainage and incision
    • SRP
    • Extraction possible
    • systemic antibiotics
  62. Indications for antibiotic therapy of periodontal abscesses
    • Cellulitis
    • Deep/inaccessible pocket
    • Fever
    • Immunocompromised
  63. Which drugs are used for abscesses if amoxicilling (penicillin) allergic?
    • Azithromycin
    • Clindamycin
  64. Pericoronal abscess
    • Usually partially erupting or impacted mandibular 3rd molars
    • Plaque retention, food impaction
    • Similar microbes to periodontal abscesses
  65. Treatment of pericoronal infecitons
    • Depends on severity
    • Systemic complications
    • Remove pericoronal flaps
  66. Why remove pericoronal flaps for pericoronal infections?
    Remove as a protective measure against acute involvement
  67. Where can untreated pericoronal infections spread?
    Into facial spaces
  68. What is the antibiotic of choice for orofacial infections?
    • Broad spectrum penicillin compounds
    • -amoxicillin
    • -augmentin (amoxicillin + potassium clavulanate)
  69. Why are antibiotics alone insufficient?
    • Insufficient penetration into abscess area
    • Enhanced resistance of bacteria within biofilm
  70. When do you refer an abscess?
    • Infection with extensive spreading
    • -periorbital, sublingual, submandibular
    • Infection not responding to treatment