Systemic antimicrobials In periodontal therapy- part 1

Question 1

Name and describe the different stages of periodontitis

Answer 1

Stage I: Initial periodontitis
Stage II: Moderate periodontitis
Stage III: Severe periodontitis with potential for additional tooth loss
Stage IV: Severe periodontitis with potential for loss of the dentition

Question 2

What is the extent and distribution of periodontitis?

Answer 2

Localised, generalised, Molar- Incisor distribution

Question 3

What are the grades of periodontitis

Answer 3

A ; Slow rate of progression
B: Moderate rate
C: Rapid rate of progression

Question 4

what are antibtiotics?

Answer 4

Drugs that kill or halt the multiplication of bacterial cells at concentrations that are relatively harmless to host tissues and therefore can be used to treat infections by bacteria

Question 5

Name and describer how antibiotics are classified

Answer 5

Beta- lactase e.g. penicillins (Beta lactase inhibitors- co amoxiclav
Aminoglycosides e.g Gentamicin
Sulphonamides e.g Sulfa/ sulpha group
Tettracyclines e.g doxy, mino
Azoles - e.g metronidazole
Quinolones - e.g Ciporfloxacin
Macrolides - E.g Erthyomycin, Azithormycin
Others - e.g clindamycin

Question 6

what do tetracyclines and macroldies do

Answer 6

inhibit protein synthesis

Question 7

what is the mode of action of systemic antibiotics

Answer 7

1. Inhibition of cell wall synthesis
2. Inhibition of cytoplasmic membrane function
3. Inhibition of nucleic acid synthesis
4. Inhibition of ribosomal function and hence protein synthesis
5. Inhibition of folate metabolism

Question 8

what do amoxycillin do

Answer 8

inhibit cell wall synthesis

Question 9

What do metronidazole do

Answer 9

Inhibit nucleic acid synthesis by breaking down strands of DNA

Question 10

What re the disadvantages of the use of antibiotics

Answer 10

• possible adverse effects
• hypersensitivtiy
• gastrointestinal disturbances
  -Alterations in commensal flora e.g Oral candidiasis , pseudomembranous colitis
• Drug interactions - alcohol - Disufiram/ potential of anitcoagulanat effect/ avoid during pregnancy
• Bacterial resistance

Question 11

How many deaths were estimated in the 2009 European centre for disease prevention with AMR (Antimibrial resistance)

Answer 11

25,000
cost 1.5 billion in extra healthcare

Question 12

what is the antimicrobial stewardship programme- NICE

Answer 12

An organisational or healthcare system wide approach to promote monitoring of judicious use of anti microbials to preserve their future effectiveness

Question 13

Describe anitmicrobila stewardship

Answer 13

Primary care prescribing alters risk of anitbitoic resistance in an individual
- Evidence based optimal standards for routine antimicrobial prescribing
Ensuring competency and education for prescribers
- Communication of issue to all stake holders
-Auditing the impact and uptake of processes above
- Optimizing outcome for patients presided anitmicorbials

Question 14

what does the anitbitoic guardian support

Answer 14

The UK antimicrobials resistance strategy
- Don’t demand antibiotics
- Take antibiotics as they are prescribed to use
-Spread the work among friends and relatives

Question 15

What are factors affecting AMR efficacy

Answer 15

• Binding of drug to tissue
• protection of key organisms by non target organisms binding or consuming drug
  -Bacterial tissue invasion
  -Total bacterial load
• Previous drug therapy
• Non pocket infected sites
  – Choice of bactericidal drug vs bacteriostatic drug (prevent growth of bacteria )
• Presence of biofilms - must disrupt
  Beta - lactase production
  some bacteria produce beta-lactaamase ( there are > 100 different types known)
  which can inactivate beta- act drugs eg. pencillin
  Clavulanic acid - beta lactamase inhibitor sometimes used in combination with amoxicillin to prevent this

Question 16

what are the Reasons for failure of anitmicorbial therapy

Answer 16

• Lack of culture and sensitivity
• Failure to achieve drainage
• Non bacterial causative agent
• Incorrect drug duration or dose
• Lack of compliance
• Defective host response
• Persistent risk factors e.g smoking
• Lack of substantivity of local agents
• Drug resistance

Question 17

which techniques do we use to monitor culture and seisnitvity to bacteria?

Answer 17

PCR
ELISA
checkerboard hybirdization
DNA analysis via nucleic acid probes
Genome tests
BANA test trypsin like enzyme chairside 19909s invalidated

Question 18

When re systemic anitbitocs indicated?

Answer 18

Maybe aggressive periodontitis
Necrotising periodontal disease
Maybe abscesses of periodontium
Maybe periodontitis associated with endodontic lesions.

Question 19

Why are antimicrobials not indicated in the treatment of chronic periodontitis

Answer 19

Antimicorbials as adjuncts to mehcnicla therapy
- deep pockets, patients with progressive or ‘ active’ disease or with specific microbiological profiles

Question 20

What are the possible antibiotic regimens for aggressive periodontitis that have been reported in the literature

Answer 20

• penicillins with or without clavulanc acid
• Tetracycline
• Macroldies
• Nitroimidaxole

Question 21

What are the drug choices as adjuncts to mechanical periodontal therapy and how frequent should you take it?

Answer 21

Amoxicillin - 500mg 2-3 x FOR 8 Days
Amoxicillin and clavulanic acid (combined) - 500 mg, 2-3 X for 8 days bactericidal , diarrhoea,colitis, nausea
Tetracyclin 500mg , 4X 21 - severe sunburn if exposure to bright sunshine
Minocylcin 100-200mg 1X for 21 days
Doxycycline - 100-200 mg, 1X 21 days
Azithromycin - 500mg 1X4-7 days
Clindamycin 300mg 2X 5-6 days
Metronidazole 500mg 2X for 8 days

Question 22

what should be carried out prior to prescription of antibiotics for treatment of periodontal disease

Answer 22

Microbial testing

Question 23

What are the benefits of a microbial test

Answer 23

• may assist chronic vs aggressive periodontitis diagnosis
• Identify specific bacteria for selection of antibiotic adjuncts
• Performed as part of risk assessment

Question 24

Why do we use systematic antibiotics in necrtoizgng periodontal disease?

Answer 24

NUG is a mixed bacterial infection caused by a group of anaerobes - spirochetes and fusiform bacteria
- These micorogrnaisms found in large numbers in the slough an nertotic tissue at the surface if the sucker and also invades greatest distance in the udnerlygn intact tissue at the base of the ulcer

Question 25

How do you manage NUG in the acute phase treatment

Answer 25

• removal of supra and sub gignaval deposits - ultrasonic scaling
• Systemic antibtioc - metronidazole tablets 200mg, 3 x daily for 3 days
• Chlorhexidine mouth rinse

Question 26

WHy do diabetic patients have multiple or recurrent periodontitis ?

Answer 26

Juveniels with diabetes may have angiopathic changes associated with lowered resistance to infection which may require the use of antibiotic following periodontal or implant surgery

Question 27

what ar considerations of diabetes that are poorly controlled

Answer 27

Infection mediated upregualtion cycle of cytokine synthesis and secretion by chronic stimulation form LPS and products of periodontopahtogenic organisms may amplify the magnitude of advanced glycation end product (AGE)- Mediated cytokine response in diabetes mellituus

Question 28

where is anitbtioc prophylaxis against?

Answer 28

Infective endocarditis

but small number of patients, may be prudent to consider antibtioc prophylaxis in consultation with he patient and their cardiologist or cardiac surgeon

Question 29

describe how periostat - sub antimicorbia dose doxyclince 20mg is used?

Answer 29

• Low dose doxycline 20mg, 2X
• Sub antimciorbial dose is NOT anitbiacterial dose
• Suggested for extended use, at least 3 months as adjunct to scaling and root surface debridement
  -similar prescribing for acne
• Claimed to reduce bystander damage
• NOT recommended at present in UK

Question 30

What are the non antibacterial effects of tetracylcines

Answer 30

• Concetrates in GCF
• Binds to root surface
• Slow release
• Fibrobalst stimualtion
• Osseous induction
• Anticollagenase (inhibits matrix metalloprotienase)