ANTIBIOTICS IN PERIODONTCS

ANTIBIOTIC
chemical substance originally produced by microorganism,either retard the growth of microorganism or result in their death
some antibiotics are chemically synthesized or semi synthesized

An Ideal Antibiotcs Should be

1. Selective and effective against micro organism 2. Bactericidal more than bacteriostatics 3 Not ineffective as a result of bacterical resistance 4. Not be inactivated by enzyme, plasma, protein or by body fluid 5. Maintained for sufficient period in blood plasma 6. Have minimal adverse effect
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Classification of Antibiotic
Based on chemical structure

1 sulfonamides- sulfadiazine, PAS

2 Quinolones - ciprofloxacin , Nalidixic acid 3 Tetracyclines Doxycycline, Tetracycline

4 Aminoglycosides Gentamycin,
streptomycin 5 Macrolides Erythromycin, Roxithromycin, Azithromycin 6 -lactam antibiotic- Penicillins Cephalosporacin
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7 Nitroimidazoles - Metronidazole, Tinidazole 8 Imidazoles derivatives- ketoconazole, 9 Polypeptides Antibiotic Bacitracin Polymyxin -B 10 Nicotinic acid derivatives Isoniazid, Pyrazinamide

Common Antibiotic used in PERIODONTCS Tetracycline Metronidazole Amoxicillin Clindamycin Cephalosporin Ciprofloxin

Antibiotic Resistance
Microorganism are some time resistant or unaffected by an antibiotic Resistance can be Natural, (before contact with drug) Acquired, (developed after exposure to drug The development of acquired resistance is genetic, with change in DNA , and is inherited by subsequent generation

* Micro organism are resistance to particular drug frequently are resistance to other chemically related antimicrobial agent This is referred as Cross Resistance * In antibiotic resistance implies In activation of antibiotic by bacterial enzyme Development of alternate pathway of drug metabolism by bacteria Biochemical alternation in the bacteria that prevent the uptake or binding of the antibiotic

TETRACYCLINE
Widely used in treatment of periodontics

Broad spectrum antibiotics

Effective aganist remove > gram- ve

MOA - inhibiting protein synthesis in

bacteria

Bacteriostatics, effective against rapidly

multiplying bacteria
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Tetracycline Effective in treating periodontal disease because

1. Their concentration in GCF is 2 to 10 times more than blood serum 2. Ability to concentrate in POCKET 3. Inhibit the growth of Actinobacillus actinomycetemcomitans 4. Have anti collagenase effect inhibiting tissue destruction 5. Increase bone regeneration
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Classification of Tetracycline based on generation Group 1 Chlortetracycline oxy tetracycline Tetracycline Group 2 Demeclocycline Methacycline Lymecycline Group 3 Doxycycline Minocycline
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Tetracyclines..........

INDICATION
Dental condition 1. Localized aggressive periodontitis

because effective against

A. actinomycetemcomitans

2. other Aggressive periodontitis. 3. Refractory periodontitis.

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Tetracyclines..........
Other condition Mixed bacterial infection - in respiratory infection - in genital urinary infection - G I T infection Contra indication Pregnancy Feeding mother Liver disorder Kidney disorder
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Tetracyclines.........

Adverse Effect
Permanent discoloration of teeth in offspring due to administration of drug during last half of pregnancy Administration of drug in 1-st 6 years of life Teratogenicty Photosensitivity GIT disorder Nausea, Vomiting, Diarrhea Epigastric distress Drecress absortion of vitamin k 14

Tetracyclines.......

Lethal hepatic toxicity if tetracycline use in renal disorder Fancony type syndrome if outdated tetracycline Use in in renal disorder
Now tetracycline less use in dental & medical, replace by more effective other combination antibiotic
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Tetracycline Staining

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METRONIDAZOLE
1. It is effective against anaerobic bacteria & anaerobic parasite 2. Anaerobic bacteria both gram +ve & gram ve 3. MOA inhibiting the growth of bacteria I by inhibit the bacterial DNA synthesis 4. On set of action 8 hours 5. Duration of action - 24-48 hours
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METRONIDAZOLE .......

More effective against obligate anaerobic gram ve bacteria DOSE Orally - 200- 400 mg tid For 7-10 day Available as Metrogyl 400 mg Flagyl 400 mg
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METRONIDAZOLE ........

INDICATION
1. Gingivitis

2. ANUG
3. Chronic Periodontitis 4. Aggressive Periodontitis In combination with amoxicillin 6. After extraction 7. All mixed infection with anaerobic bacteria 8. In severe odontogenic infection with other antibiotic
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5. In Refractory Periodontitis

METRONIDAZOLE ..........

Contra indication
1. Patient having alcohol habit 2. Patient taking anticoagulant therapy B/C it prolonge the pro thrombin time 3. CNS disorder 4. Blood disorder 5. Cirrhosis of liver 6. Renal disorder
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METRONIDAZOLE ..........

Adverse Effect
1. Abdominal problem Severe cramp, Nausea, Vomiting, Diarrhea 2. Metallic taste in mouth 3. Headache disorder 4. Dry mouth Not use as mono therapy for treatment of periodontal disease
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Penicillins
These are B lactam antibiotic Types Penicillin G (Benzyl Penicillin ) acid labile destroyed by gastric acid Penicillin- V acid stable ( given orally ) Penicillinase resistance penicillin Methicillin , cloxicillin, Oxacillin Extended spectrum Penicillin amphicilin, amoxicillin, bacampicillin
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AMOXICILLIN
Amoxicillin is a semi synthetic antibiotic Known as Broad spectrum penicillin Effective against gram- ve bacteria MOA of action Inhibit synthesis of bacterial cell wall Onset of action - 1-2 hours Duration of action - 8 hours
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Amoxicillin .......
It show excellent absorption after orally administration It susceptible to penicillanase (Beta lactamase) produced by bacteria For Periodontal therapy Given combined with clavulanate Amoxicillin + Clavulanate = AUGMENTIN It is against the penicillanase

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Amoxicillin .......

INDICATION
1 As prophylaxis therapy before any periodontal surgery 2 Amoxicillin + Metronidazole In localized juvenile periodontitis 3 Amoxicillin +clavulanate In refractory periodontitis 4 In all other aerobic infection

Contra Indication
Hypersensitivity to penicillin
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Amoxicillin .......

DOSE 250 500 tid route of administration Orally, IM, IV

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Amoxicillin ....... ADVERSE EFFECT

Amoxicillin is a safe drug un till it is hypersensitive to patient Toxicity to amoxicillin is rare Diarrhea Super infection Nausea , Epigastric distress Bleeding disdorder Urticaria Allergic reaction Bacterial resistance

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CLINDAMYCIN
It is macrolide MOA Inhibit protein synthesis in bacterial cell wall As a nature - Bacterio static but in high dose Bactericidal It has ability to penetration in deeper tissue like bone and deep tissue , so has importance in treating periodontal disease 28

Clindamycin ........
After oral administration Level in bone similar to level in blood Level in GCF is more than MIC required Effective against anaerobic bacteria

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Clindamycin ........
INDICATION
Treatment of refractory peridontitis alone or in combination with amoxicillin Dose 150 mg tid for 7-10 day ANUG In deep odontogenic infection Osteomyelitis
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Clindamycin ........

Contra Indication
Hypersensitivity Liver disorder Renal failure Blood disorder

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Clindamycin .......

ADVERSE EFFECT
1. Main side effcet is Diarrhea ,gastric upset if taken in empty stomach 2. Ulcerative colitis 3. Anorexia, metallic taste 4. Allergic reaction 5. Aplastic anemia 6. Insomnia

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CIPROFLOXACIN
It is first generation fluoroquinolone Effective against gram ve bacteria including all facultative bacteria &some anaerobic putative periodontal bacteria Dose- 500 mg bid Dose should be change according to severity of disease MOA Inhibit bacterial DNA synthesis Onset of action -1 hours Duration of action 8 to 12 hours
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Ciprofloxacin ......

INDICATION
1. In Refractory Periodontitis 2. In combination with Metronidazole effective against A. actinomycetemcomitans Non Dental Condition Typhoid Gonorrhea Skin & Soft tissue infection Urinary tract infection

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Ciprofloxacin ......

Contra Indication Hypersensitivity Special Precaution Renal disorder Epilepsy Children

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Ciprofloxacin .....

ADVERSE EFFECT
Nausea vomiting Headache Abdominal discomfort

Inhibiting metabolism of theophyllline, warfarin &anticoagulant

Photosensitivity , Hyper pigmentation,

Hypersensitivity
Insomnia
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Locally Delivered of Antibiotic

Limitation of systemic therapy, mouth rinse & irrigation have, promoted for research for development of alternative delivery system Requirement of treating periodontal disease include 1. Controlled release of drug 2. Maintained localized concentration of drug at infection site for optimum time 3. Minimal side effect 37

Various Locally Delivered of Antibiotic

ACTISITE ARESTIN ATRIDIOX PERIO CHIP (Tetracyclines) (Minocycline) (Metronidazole ) (Chlor hexidine)

Elyzol

(Metronidazole )
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Powered irrigation device

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Tetracycline Containing Fiber

(ACTISITE ))
First local delivery product for antibiotic Feature
1. Ethylene or vinyl acetate copolymer fiber 2. Diameter 0.5 mm 3. Containing Tetracycline 12.7 mg/ 9 inch 4. When packed into periodontal pocket, it is well tolerated by oral tissue 5. For 10 day it sustains tetracycline concentration exceeding 1300 ug/ ml
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ACTISITE

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Actisite.......
Effect
Reduction in probing depth Reduction in Bleeding on probing Increase in clinical attachment level Normally no staining on teeth

Reduction in plaque micro organism

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Sub Gingival Delivery Of Doxycline ATRIDIOX

Atridox is gel system that incorporate the antibiotic Doxycycline (10%) in syringe able gel system It is a Biodegradable mixture Drug introduced Subgingivally Applied with or without Scaling or Root planning

Effect
Increase in clinical attachment level Reduction in plaque micro organism Probing depth reduction

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ATRIDIOX

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Sub Gingival Delivery For Minocycline (ARESTIN)

1. Sub Gingival Delivery system contain 2% (w/w) Minocycline hydrochloride 2. Use as a adjuvant to Sub Gingival debridement 3. Biodegradable mixture in syringe Effect are Reduction in Pocket depth Reduction in gingival bleeding Reduction in plaque microorganism
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Sub Gingival Delivery Of METRONIDAZOLE

ELYZOL

ELYZOL Containing an oil based

Metronidazole 25% dental gel Applied in viscous consistency to the pocket where is liquidized by body heat and hard again contact with water Preparation contain Metronidazole benzoate, which is converted into active substance by esterase in GCF Effective after scaling &Root planning
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Local Delivery Of Antiseptic Agent

Chlorhexidine delivery system (Perio chip) It is a resorbable delivery system periochip ,tested for Chlorhexidine gluconate It is small chip 4 x 5 x .35 mm Composed of Bio degradable hydrolyzed gelatin matrix Cross linked with glutraldehyde Glycerin with water 47

PERIO CHIP
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 It is rounded on one end so easily inserted Perio chip released Chlor hexidine and maintain drug concentration in GCF more than 1000 ug/ml for atr least 7 day Bio degradable in 7 to 10 day

Advantage
Reduction in probing depth Reduction in Bleeding on probing Increase in clinical attachment level Normally no staining on teeth

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REFERENCES
Jan Lindhe Clinic Periodontology & Implant Dentistry, Fourth Edition. Carranzas Clinic Periodontology, Ninth Edition. J D Manson & B M Eley Outline of Periodontics, Fourth Edition. Guru Raja Rao Text Book Of Periodontology, Second Edition. Periodontal Medicine, Rose, Genco, Cohen Menley

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