antibiotic & antiseptic use in periodontal therapy

7/21/2019 Antibiotic & Antiseptic Use in Periodontal Therapy

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Antibiotic & Antiseptic

Use in PeriodontalTherapyDr Sushil Kaur

BDS MDSc (Perio) DClinDent (Perio

FRACDS (Perio)

Dr.Betul Rahman

BDS, PhD.



2



Introduction• Microbial aetiolog

(Bacteria !ithin "ental #la$ue bio%ilm)

• Bacteria essential but insu%%icient %or "e&elo#ment o%

#erio"ontitis

• 'ost susce#tibilit "estructi&e immunoin%lammator

res#onse to subgingi&al #la$ue bacteria

ingi&itis Perio"ontitis



Microbial Aetiology

• *&er + s#ecies in subgingi&al %lora

• *nl a %e! s#ecies clearl associate" !ith #erio"ontitis

• Aggregatibacter actinomcetecomitans (A.a)

• Por#hromonas gingi&alis (P.g)

• -anerella %orsthensis (-.%)

• -re#onema "enticola (-.")

('a%%aee / Socrans0 122341225)

• Man s#ecies still uni"enti%ie"



Periodontal Disease – Control ??

• Control host res#onse mo"i%ing %actors

• 6limination o% #la$ue retenti&e %actors

• Disru#tion an" re"uction o% #la$ue bio%ilm

• Shi%t o% microbial %lora com#osition



Limitations o Treatment

• 7ocal anatom Root conca&ities, groo&es an"

%urcations

• Bacterial in&asion o% gingi&al tissue

• 8nabilit to "isru#t bio%ilm an" su##ressbacteria to a le&el com#atible !ith the host

• Re"uce" treatment outcome associate"

!ith ele&ate" #erio"onto#athogen le&els

• Ma e9#erience ongoing #erio"ontal

brea0"o!n

:ee" %or a"uncti&e thera#;

Antibiotic thera#;

Sstemic or local "eli&er;



Antibiotic therapy

• :atural or snthetic organic

substances that can inhibit or 0ill

selecti&e microorganisms

• Multi<million "ollar in"ustr

• 8n 1225, o&er 1.= billion >SD !as

s#ent on #romotion

• 8n the >SA, o&er 1 million

0ilograms o% antibiotics are

#rescribe" %or human use annuall



!acterial "esistance

• Antibiotic use a #rimar %actor

• 8ntrinsic, mutational or ac$uire"

• Selection o% resistant s#ecies

Methicillin Resistant Sta#hlococcus aureus (MRSA)

?ancomcin Resistant Sta#hlococcus aureus (?RSA)

@hat "oesnt 0ill them ma0es them stronger

Periodontal !acterial "esistance• ram &e s#ecies (Pre&otella) #ro"uce <lactamases

• <lactamases "etecte" in #erio"ontal #oc0ets

• -etraccline resistance

• Resistance associate" !ith increase" antibiotic use



!acterial "esistance in Dentistry

• Dentistr < a##ro9imatel 1E o% all antibiotic

#rescri#tions • Poor #rescribing contributing to bacterial resistance

• Recent sur&e suggests

3GE o% "entists #rescribe"

!ithout a "iagnosis HE o% "entists #rescribe"

"ue to time #ressures

!acterial "esistance – Pre#ention

• Iu"icious use o% antibiotics• Selection o%

A##ro#riate clinical scenario %or antibiotic use

A##ro#riate agent %or each clinical scenario



$% Antibiotics ha#e the potential tocause harm

• Allergies an" '#ersensiti&ities

1=E o% all "rug relate" a"&erse e&ents

#resenting to the 6mergenc

De#artment Commonl Penicillin

Allergic reactions to Penicillin ranges

%rom .GE to 1E among the general

#o#ulation Ana#hla9is ris0 .3<.11E

Fatal ana#hla9is ris0 .JE

Can "e&elo# at an e9#osure to "rug



• A"&erse Reactions

:ausea an" Diarrhoea• *##ortunistic in%ections

Pseu"omembranous colitis

Can"i"osis

• Drug interactions ar%arin

Alcohol

• -o9icit -eratogenic e%%ects

Breast%ee"ing



% Antibiotics should be used in limitedclinical situations

• Pro#hla9is or -hera#

• Pro#hla9is

8mmunosu##resse" in"i&i"uals 8n%ecti&e 6n"ocar"itis

• 8n"ications shoul" be consi"ere" in light o% recentl

u#"ate" gui"elines

(8n%ecti&e 6n"ocar"itis Pro#hla9is 69#ert rou#, J5) (Dal et al. J5) Pre&ention o% #osto#erati&e in%ection;;;

8m#ro&e #erio"ontal regenerati&e outcome;;;



Pre#ention o postoperati#e inection• Antibiotics #rescribe" o%ten %or #erio"ontal an" im#lant surger

• Rate o% #osto#erati&e in%ection lo!

1E < +E• :o a"&antage "emonstrate" in re"ucing

#osto#erati&e in%ection a%ter

ingi&ectom

*sseous resecti&e surger Mucogingi&al surger

*sseous gra%ting

• Re"uce" in%ection rate !hen C'L use"



Implant surgery :o "i%%erence in #osto#erati&e in%ection rates

Role in re"uction o% im#lant %ailure contro&ersial

• 8m#ro&e" sur&i&al (J39 higher)

• :o "i%%erence in sur&i&al

• Recent stu"ies suggest

a single #reo#erati&e antibiotic "ose more a##ro#riate

Similar in%ection or sur&i&al rates !hen com#are" to #re<an" #osto#erati&e regimen

• Cochrane re&ie! b 6s#osito et al.,(J5b)Metaanalsiso% J RC-

• Bene%it o% #osto#erati&e antibiotics unclear • Jg o% Amo9icillin 1hr #reo#erati&el

Signi%icantl re"uce" earl im#lant %ailures

:o e%%ect on #osto#erati&e in%ection



Implant surgeryConsiderations or antibiotic prescription'

Patient %actors

7e&el o% ase#sis

Com#licate" or #rolonge" #roce"ure

Bone gra%ting

*#erator e9#erience (+ im#lants)

Chlorhe9i"ine mouthrinses re"uce" in%ection an" im#lant%ailure



Periodontal regeneration

Microbial colonisation o% membrane

associate" !ith re"uce" CA7 gain

Most stu"ies ha&e inclu"e" sstemic

antibiotics "uring the %irst an"4or secon"

!ee0 o% membrane #lacement



Periodontal regeneration

8m#ro&e" clinical outcomes !ith e<P-F6 membranes

in #atients using sstemic antibiotics com#are" to

#atients not recei&ing antibiotics

• Amo9icillin !ith Cla&ulanic Aci" (Augmentin)

:o "i%%erence in clinical outcomes !ith Bioresorbable

membranes• Amo9icillin N Metroni"aOole

Stu"ies using 6m"ogain ha&e utilise" a"uncti&e

antibiotics

:o a""itional bene%its !ith a"uncti&e Amo9icillin an" Metroni"aOole



• Antibiotics shoul" not be use" ust in case

• :o in"ication %or routine #erio"ontal surger

• :o in"ication %or #erio"ontal regeneration !ith6m"ogain

• 7imite" e&i"ence %or #erio"ontal regeneration!ith membranes

• 7imite" e&i"ence %or routine im#lant surger



Therapy :ecrotising >lcerati&e ingi&itis (:>)

Perio"ontal abscess

Perio"ontitis;;;;

• May be useul in'

7ocalise"4eneralise" Aggressi&e #erio"ontitis

Re%ractor "isease

• (reatest impro#ements in sites )*mm

• Minimal beneit in chronic periodontitis

Res#on"s !ell !ith con&entional #erio"ontalthera#



+% Antibiotics used as an ad,unct- notreplacement in periodontal therapy• Subgingi&al #la$ue bio%ilm

– Diverse microbial community

– Exists outside of host

– Barrier to diusion

– Increased antibiotic resistance

• 'igh gingi&al cre&icular %lui" (CF) le&els re$uire" %orbio%ilm #enetration

• Sstemic antibiotics alone– GCF levels may not penetrate biolm

– Does not remove plaue retentive factors such assub!in!ival calculus

Current e#idence suggests that the use o

antibiotics alone are ineecti#e in the treatment

o periodontitis



• A"unct to subgingi&al "ebri"ement 8mme"iatel a%ter initial #hase

At re<e&aluation #hase

• Qualit o% subgingi&al "ebri"ement a%%ects treatment

outcome

• Poorer outcome !hen #er%orme" b stu"ents or less

e9#erience" clinicians



.% Dierent agents or dierent situations

-etracclines

Metroni"aOole Amo9icillin4Metroni"aOole

AOithromcin

• 8m#ortant thera#eutic consi"erationsMe"ical status an" concomitant me"ications

7i0el microbial s#ecies7ac0 an eas to use, cost e%%ecti&e microbiological test

:ot all aetiological s#ecies i"enti%ie"

7imite" antibiotic agents a&ailable

Most regimens remain largel em#irical

7imite" e&i"ence %or o#timal "osage an" "uration



"eractory Periodontitis• Polmicrobial (A.a, P.g, -.%, P.i, Stre#.)

• Consi"erations :umber o% unres#onsi&e sites

'ost res#onse

Presence o% mo"i%ing %actors

69ten"e" antibiotic "uration in smo0ers

• Metronida/ole (*bligate anaerobes,A.a,gram &e) J<3mg t"s + "as

HG+mg4J+mg t"s + "as

• A/ithromycin

+mg once "ail H "as

7imite" e&i"ence Bene%it in "ee# sites an" smo0ers



Aggressi#e Periodontitis

Localised Aggressi#e

• A.a im#licate"

• -etracclines

-etraccline 'Cl J+mg $"s13 "as

• A.a not su##resse" at all

sites

Resistance ?ariable CF concentration

(eneralised Aggressi#e

• Polmicrobial

(P.g, -.% N4< A.a)

• -etracclines 7imite" or no e%%ect



Aggressi#e Periodontitis

• Amo0icillin1Metronida/ole

J+<+mg4J<3mg t"s + "as

• A/ithromycin

+mg once "ail H "as

6arl e&i"ence #romising

Localised Aggressi#e (eneralised Aggressi#e



A/ithromycin

• Macroli"e

• Fe! a"&erse e%%ects

• i"e antimicrobial s#ectrum

" Aerobic an" anaerobic bacteria" 6%%ecti&e against

A.actinomcetemcomitans an" P.gingi&alis

• 'igh #erio"ontal tissue concentrations

%or + "as a%ter a"ministration• 8m#ro&e" #atient com#liance



(eneralised Aggressi#ePeriodontitis

BaselineBaseline

# months post treatment# months post treatment



Localised Aggressi#ePeriodontitis

BaselineBaseline

$% months post treatment$% months post treatment

% months post% months post

treatmenttreatment



2% Antibiotics can result in re

inection1recolonisation

• A.a, P.g, -.%, -."

• Recolonisation

Su#ra an" subgingi&al #la$ue

Mucous membranes, tongue, tonsils

• Regular bio%ilm "isru#tion re$uire" "uring SP-



Conclusions• Antibiotics are &aluable thera#eutic agents

• :ot magic bullets• i"es#rea" use bacterial resistance

• Clinicians nee" to be res#onsible %or sensible #rescribing

• 7imite" clinical scenarios

• :ot an e9cuse %or #oor surgical techni$ue• Ris0s o% com#lications ma be greater than the ris0 o%

#osto#erati&e in%ection occurring

• Ris0 small at a #atient le&el but signi%icant ris0 at

#o#ulation le&el %or #re&entable a"&erse e&ents

• Diagnosis im#ortant



• :ot an e9cuse %or ina"e$uate "ebri"ement

• A"unct to re"uce le&el4com#osition o% bacteria to

one com#atible !ith host

• 8m#ortance o% host res#onse an" mo"i%ing%actors

• Most regimens largel em#irical

• Further stu"ies re$uire" to #ro&i"e gui"elines



Chemical Pla3ue Control

Mouthrinses



Pla3ue control

• -oothbrushing

• hen goo" oral hgiene is #ractice",

mechanical toothbrushing can remo&e #la$ue

e%%ecti&el

• Moti&ation ten"s to "ecline o&er time

• 8n in"ustrialise" countries, the a&erage #erson

brushes %or less than one minute• Combination o% mechanical an" chemical oral

hgiene a##ear to o%%er some bene%its

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The concept o chemical pla3ue control

• -he nee" to %urther im#ro&e #la$ue remo&al %orms the basis o%

@chemical #la$ue control• Pre&ention o% gingi&itis is base" on the assum#tion that gingi&itis

is the #recursor o% #erio"ontitis

So ho! o%ten "oes gingi&itis #rogress to periodontitis&

• Poor #re"ictor %or %uture #erio"ontitis• -he #ro#ortion o% gingi&al lesions that con&ert to #erio"ontitis is

currentl un0no!n• -he %actors that cause the con&ersion are not !ell un"erstoo"• -he most con&incing e&i"ence that gingi&itis "o not #rogress to

#erio"ontitis comes %rom e#i"emiological stu"ies on untreate"#o#ulations in China, Kena, an" :igeria.



45A467 III

• >S :ational 'ealth an" :utrition 69amination Sur&e (Alban"ar et al .12224 JJ)

• H 515 subects to re#resent J3G million >S #o#ulationFor a"ults (H<2rs) !ith = teeth

• +%$8 ad#ance periodontitis• 2.+E mo"erate #erio"ontitis• J1.5E mil" #erio"ontitis• =+.+E no #erio"ontitis

• A"ults =rs an" ol"er in SA, le&el o% #erio"ontitis broa"l similarto :orth America (Sla"e / S#encer 122+)

• (enerally agreed that se#ere generali/edperiodontitis aects 29$28 o the population

• (AAP J+).



Chemical pla3ue control agents':irst- second- third generation

$% :irst9generation' "o not e9hibit an signi%icantsubstanti&it (onl minutes)

% 7econd9generation antimicrobial agents highsubstanti&it (hours)

+% Third9generation' mo"erate substanti&it (hours)

• 7econd9generation antimicrobialagents are still the agents o choice(Consensus re#ort Jn" 6uro#ean or0sho# on Perio"ontolog 122=)



• First generation agents can 0ill bacteria on contact,

but ha&e limite" abilities to e9ert an e%%ect on the oral

%lora a%ter e9#ectoration (e.g. cetl#ri"inium chlori"ean" sanguinarine),

• Secon" generation agents ha&e an imme"iate

antibacterial e%%ect an" more im#ortantl, ha&e a#rolonge" e%%ect on the oral %lora (e.g. chlorhe9i"ine).

• -hir"<generation agents are characteriOe" b an

abilit to inhibit or "isru#t the %ormation o% #la$ue

!hile ha&ing no "emonstrable e%%ect on bacteria.

(-he mor#holinoethanol "eri&ati&e<"elmo#inol)



Mouthrinse

• Mouthrinses generall contain three basicingre"ients

• Alcohol < to enhance %la&our im#act an"solubiliOe the %la&our an" some acti&eingre"ients also acts as a #reser&ati&e.

• 7uractants 9 "ual %unction to assist in theremo&al o% "ebris %rom the mouth an" #ro&i"eantibacterial e%%ects ai" in solubilisation o%

%la&our an" some acti&e ingre"ients.• :la#ouring agents 9 #ro&i"e some breath<%reshening #ro#erties.

( t d t t l



(roups o agents used to controlpla3ue and1or gingi#itis

• 1. Bisbiguani"e antise#tics• J. Quaternar ammonium com#oun"s

• H. 6ssential oils (6*)

• 3. :atural #ro"ucts• +. *9genating agents

• =. Amine alcohols

• G. *ther



Chlorhe0idine ;C5<=

• Bisbiguani"e antise#tics• C'L is the most stu"ie" an"e%%ecti&e antise#tic in thiscategor

• De&elo#e" in the 123s in6nglan"

• Cationic antise#tic• Broa" s#ectrum antimicrobial• A%ter J ears o% use b the

"ental #ro%ession, C'L isrecogniOe" as the (>LD stan"ar" against !hich otheranti#la$ue an" gingi&itisagents are measure"



The mechanism o C5< eect

-he anti#la$ue e%%ect o% C'L can be h#othesiOe"as

• An bacteria a"hering to the tooth sur%ace are

either 0ille" (bacterici"al e%%ect) or are #re&ente"%rom multi#ling (bacteriostatic e%%ect)

• -he #ersistent, bacteriostatic e%%ect o% C'L is!hat ma0es C'L the gol" stan"ar"

>ptimi ing the se o



>ptimi/ing the use ochlorhe0idine

• C'L shoul" not be use"

be%ore, or imme"iatel

a%ter using tooth#aste (or

else it !ill re"uce the e%%ecti&e "eli&er

o% C'L to the tooth sur%ace in an

acti&e %orm)

• 7imit inta0e o% %oo"s an"

be&erages "uring

treatment !ith C'L,

es#eciall ust a%ter use!ith C'L

t i

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uaternary ammoniumcompounds

• Cetl#ri"inium chlori"e (CPC)• CPC mouthrinses ha&e been mar0ete" inthe >SA since 123

• Cationic in nature.

• CPC is use" in a !i"e range o% antise#ticmouthrinses• CPC has a broa" s#ectrum antimicrobial

acti&it• Substanti&it is less than C'L T H hours

(Roberts / A"" 1251)• 7ittle e&i"ence o% an bene%its to im#ro&e

gingi&itis



7ide eects o CPC• CPC shares some o its side eects as C5<• -ooth staining• Calculus %ormation• Burning sensation• :o clinical trials su##ort the use o% CPC as an anti<

#la$ue or anti<gingi&itis agent



6ssential oils ;6>=

• A##ro&e" in 125G in America

• Contain J #henol<relate"essential oils

• -hmol .=3E,6ucal#tol .2JE• @Listerine is a

breakthrough against plaque and it’s the onlymouthrinse that can breakthrough plaque and kill thebacteria.” - ana"&ertisement %or 7isterine



5o@ does Listerine @or?

• Microorganisms are 0ille" b "isru#ting their cell !alls an" binhibiting their enOme acti&it

• Pre&ents bacteria %rom aggregating, an" slo!s bacterial#roli%eration

• Re"uces bacterial loa"

• A recent sstematic re&ie! on essential oils conclu"e"Bhen used as an ad,unct to unsuper#ised oralhygiene- 6> pro#ides an additional beneit @ithregard to pla3ue and gingi#itis reduction ascompared to a placebo or control mouthrinse

• Some stu"ies suggest as an alternati&e to C'L (PiOOo et

al. J5)

• Com#are" to C'L, e%%icac o% 7isterine isin%erior (Paras0e&as J+ Stoe0en et al . JG)



7aety o Listerine

• 7ong<term use sa%e (al0er et al. 1252)

• Concern has been raise" about the associationo% long<term use o% a high<#ercentage alcohol<

content mouthrinse !ith oral cancer (6lmore / 'or!itO122+)

• :o e&i"ence o% cancer (Cole et al. JH inn et al. J1 Carretero

PelaeO et al . J3)

• Possibilit o% #ro"ucing #athological change

shoul" be borne in min" !hen consi"ering long<term use o% a mouth!ash o&er a li%etime (Paras0e&as

J+)



4atural products

• 'erb an" #lant #ro"ucts ha&e been use" %orman ears i% not centuries

• -he bloo" root #lant Sanguinaria

cana"ensis #ro&i"es an al0aloi" e9tract

calle" @sanguinarine• -he #ro"uct is incor#orate" in mouthrinse

%ormulations / !ith Oinc chlori"e (salts) to

enhance the anti<#la$ue e%%ect (!hich ma0es it

"i%%icult to e&aluate the e%%icac o% sanguinarine alone)

• 7imite" bene%it (e&en !hen combine" !ith Oinc) (Quirnen et al . 122)



>0ygenating agents

• 'J*J

• Most commonl use"

in cases o% A:>

an" #ericoronitis

• 7imite" e&i"ence

a&ailable to suggest

use as anantigingi&itis or

anti#la$ue agent



Amine alcohols

• Consi"erable #romise as anti#la$ue agents• *cta#inol !as %irst stu"ie", !ith"ra!n %or to9icologicreasons

• Delmo#inol %ollo!e" at .1E an" .JEconcentrations in mouth!ashes

• Man si"e e%%ects ha&e been re#orte" tooth"iscolouration transient numbness o% the mucosasuch as the tongue taste "isturbance an" burningsensations in the mouth

• hen com#are" to C'L, e%%ecti&eness !as %arbelo! C'L (7ang et al. 1225)

• :o #ro"ucts o% Delmo#inol are a&ailable



>ther antiseptics

• Man other agents ha&e been stu"ie" but most ha&ebeen %oun" to ha&e little or no e%%ect clinicall

• Po&i"one io"ine at 1E has a

substanti&it o% onl 1 hour (A"" / right 12G5)

minimal #la$ue inhibitor acti&it (A"" et al.

12GG) or action in acute in%ections (A"" / 7le!eln

12G5) As a rinse, has #otential to a%%ect throi" %unction(ra et al. 12GG)

Can mouthrinses treat



Can mouthrinses treatperiodontitis??

• -he use o% mouthrinses is increasing, es#eciall asa"uncts to the "ail mechanical oral hgiene (:etuschil,

JH) • @Mouthrinsing %aile" to achie&e an signi%icant

#enetration o% #oc0ets (Pitcher et al. 125)

• -he lac0 o% #enetration ma ha&e been "ue to the

#resence o% subgingi&al calculus or o% a ban" o% tightl

a"a#te" #oc0et e#ithelium imme"iatel coronal to the

e#ithelial attachment (:e!man 12G=)

• Conclusion that mouth!ash "oes not a%%ect

subgingi&al #la$ue ;FlUtra et al. 12GJ)

I di ti



Indications or use omouthrinse as an ad,unct

1. A%ter surgical #roce"ures

% 8n me"icall com#romise" #atients those

recei&ing chemothera# or ra"iothera#

an" bone marro! trans#lant #atients



Conclusion

• C'L is the *7D stan"ar" %or mouthrinse• C'L mouth!ash "oes not a%%ect subgingi&al

#la$ue "ue to the lac0 o% subgingi&al#enetration

• 7imite" use in treatment o% #erio"ontitis

• Mouthrinses ha&e a role in gingi&itis #re&ention,but consi"ering gingi&itis "oes not necessaril

#rogress to #erio"ontitis, !e nee" to $uestion!hether the use o% chemical agents %or thegeneral #o#ulation is reall necessar



Acno@ledgement

• D" "AEM>4D C5A4

• D" TI4A C5>>

antibiotic & antiseptic use in periodontal therapy

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