Local and systemic antimicrobials in the management of inflammatory periodontal diseases

Question 1

How is plaque controlled mechanically?

Answer 1

Pt performed
Non-surgical root surface cleaning
Surgical root surface cleaning (flap)

Question 2

When are systemic antimicrobials used with mechanical treatment?

Answer 2

Aggressive forms of periodontitis
Necrotising forms of PD (NUG, NUP)
Perio abscess
Deep perio pockets not responding to RSD
Progressive or active disease
Guided tissue regeneration

Question 3

Examples of antimicrobials for systemic use

Answer 3

 Tetracyclines (historical)
 Metronidazole
 Combinations of
metronidazole and amoxicillin
 Azithromycin

Question 4

How to treat aggressive periodontitis?

Answer 4

Metronidazole (400mg) and amoxicillin (500mg) both TDS, 7
days
Azithromycin 500mg daily for 3 days

Question 5

How to treat pockets not responding to RSD - progressive or active disease?

Answer 5

Amoxicillin / metronidazole
combination
Azithromycin

Question 6

How to treat periodontal abscesses?

Answer 6

 Metronidazole
 Amoxicillin/Clavulanic acid
 Azithromycin
 Tetracycline

Question 7

Negatives of Azithromycin?

Answer 7

Can prolong QTc interval -also an effect of some other drugs – increased risk of abnormal heart rhythm
• Interaction with statins
• Must check BNF / check with pharmacist or GP if in doubt

Question 8

What are the problems of evaluating systemic antibiotics?

Answer 8

 Prospective, randomized placebo-controlled,
double blind trial ideal
 Majority of older studies fall short
 Evidence base emerging following more recent studies

Question 9

Systematic review evidence for systemic antimicrobials?

Answer 9

(Herrera et al. 2002)
• Additional benefit (CAL/PPD) - deep pockets
• Reduced risk of further CAL loss - progressive or
“active” disease
• Aggressive disease - might have adjunctive benefit
• Amoxicillin and metronidazole combination
If systemic antibiotics are to be used, they should commence at the completion of RSD, which should be completed within one week (Herrera et al. 2008)

Question 10

Evidence for azithromycin?

Answer 10

Improved outcomes in chronic periodontitis in deep pockets:

- Smith et al

Question 11

Advantages of systemic antimicrobials?

Answer 11

Useful for aggressive / active / progressing sites
(pus formation)
Multiple sites
Low cost
Less clinical time

Question 12

Disadvantages of systemic antimicrobials?

Answer 12

 Dependent on patient compliance
 Unwanted side effects
 Can produce microbial resistance to
antimicrobials
 Can lead to sensitivities and allergies

Question 13

Examples of locally applied antimicrobials?

Answer 13

 Metronidazole (Elyzol)
 Chlorhexidine (PerioChip) (Chlosite
gel)
 Minocycline (Dentomycin)*
 Doxycycline (Atridox)*
(* no longer available in UK

Question 14

Indications for locally applied antimicrobials?

Answer 14

FEW SITES
POOR RESPONSE TO DEBRIDEMENT
DEEP SITES IN MAINTENANCE PATIENTS

Question 15

What is metronidazole 25%? How does it work?

Answer 15

Semi-solid suspension gel (25% metronidazole)
• Forms “liquid crystals” on contact with water
• Water in matrix dissolves metronidazole –
diffuses into surroundings
• Stable for 3 years if above 25 degrees

Question 16

How to use metronidazole?

Answer 16

• Subgingival debridement first
• Syringe into pocket until over
flowing – wipe off excess
• Reapply one week later

Question 17

Does metronidazole gel work?

Answer 17

 Effective antimicrobial conc. < 1 day
 Substantial amount swallowed
- Ainamo et al J Clin. Periodontol. 1992 ;19:723-729

Question 18

Does Elyzol work?

Answer 18

May enhance effects of SRP
Not for treatment of refractory or aggressive
periodontitis, periodontitis in patients with
predisposing illness or those under medical
treatment, grade III furcations
Contra-indicated in patients allergic to sesame seeds
and other precautions

Question 19

When is elyzols preferred use?

Answer 19

As an adjunct - slow progessing periodontitis, grade II furcations, angular bony defects

Question 20

What is periochip? How does it work?

Answer 20

Chlorhexidine digluconate 2.5 mg in gelatine
• Minimum depth > 5mm
• Biodegrades releasing
chlorhexidine over 7–10 days

 PerioChip replaced at 3m & 6m, if PD > 4mm remained
 At 9m: Significant  PD &  AL in PerioChip group

Question 21

Does periochip work?

Answer 21

• Enhanced effects of SRP especially deep sites
• Gain in bone noted and/or no loss, whereas 25% showed bone loss
with SRP alone

Question 22

What is chlosite?

Answer 22

Xanthan gel and chlorhexidine (0.5% as digluconate and 1.0% dihydrochloride)

Question 23

When and how to use minocycyline 2%?

Answer 23

• Moderate to severe chronic periodontiitis
• Adjunct to root surface debridement of
sites  5mm in depth
• Not to be repeated within 6 months

Question 24

What is doxycycline 8.5%? How does it work?

Answer 24

 Gel that solidifies in minutes
 Does not flush out
 Sustained release 7-10 days
 Absorbed and does not require removal
 Effective against periodontal pathogens

Question 25

Does atridox work?

Answer 25

• Enhanced effects of root surface debridement
• Works in smokers
• Suggested use for non-responding sites
• No longer available in UK

Question 26

Advantages of locally applied antimicrobials?

Answer 26

 High local concentration of antimicrobial with
minimum unwanted side effects
 Less reliance on patient compliance
 Useful for isolated sites

Question 27

Negatives of locally applied antimicrobials?

Answer 27

 More expensive

 Effective?

Question 28

Do locally applied antimicrobials work?

Answer 28

Additional improvement in probing and clinical
attachment (mean < 1mm) v RSD alone
Increased number of sites with PPD reductions
≥ 2mm

Conflicting evidence on the use of chlorhexidine in a gelatin chip (Cosyn
and Wyn, 2006)
Insufficient evidence to support the use of a chlorhexidine
gel (Cosyn and Sabzevar, 2005)