Use of antimicrobial agents in periodontal therapy

Question 1

Discuss the properties of chlorhexidine in the management of gingival and periodontal disease

Answer 1

 Anti-plaque agent – prevents plaque
accumulation on tooth surface

 Anti-microbial: mode of action - membrane
disruption – highly cationic

 Highly effective - gold standard:
Gm+ve/Gm-ve bacteria, aerobic and
anaerobic, yeasts

 Substantivity: ability to bind to soft and
hard tissues, increasing working time

Question 2

Discuss the delivery systems of chlorhexidine in the management of gingival and periodontal disease

Answer 2

UK/Europe: 0.2%
chlorhexidine gluconate,
10ml rinse (20mg)

Corsodyl Daily Defence
 0.06% Chlorhexidine
Digluconate
 0.0553% sodium
fluoride (250ppm)
 Everyday usage
 Staining??

Chlorhexidine gel
* Gingivitis associated with Mouthbreathing
* Use on Tepe brushes to access interproximal
sites

Periochip
 Slow release chlorhexidine from
bovine gelatin carrier
 Contains 2.5mg chlorhexidine
 Peak concentration @ 2 hours
 Continued release over 10 days
 Self-retentive in pocket
 No bacterial resistance
 ≥5mm pocket depth
 Repeat placement every 3
months

Question 3

explain use of chlorhexadine to a patient

Answer 3

 Interacts with toothpaste components (sodium
lauryl sulphate): use at least 1 hour before/after
toothbrushing
 Avoid longterm usage – advise once/twice per
day for up to 7 days during active treatment
 Side-effects: staining (so avoid tea, coffee and red wine, these have high levels of tannins which bind to (root) surfaces), taste sensation, parotid
swelling, hypersensitivity/anaphylaxis

Question 4

Discuss the use of chlorhexidine in the management of gingival and periodontal disease

Answer 4

 Aid to toothbrushing and interdental cleaning
Post-scaling and root instrumentation when tissues may be sore/sensitive; patient’s plaque control not optimal; significant gingival inflammation.
Post periodontal surgery
Acute gingival infections

Question 5

Prescribe chlorhexadine mouthwash to a patient

Answer 5

0.2%
chlorhexidine gluconate,
10ml rinse (20mg)

Question 6

Corsydyl daily defence

Answer 6

 0.06% Chlorhexidine
Digluconate
 0.0553% sodium
fluoride (250ppm)
 Everyday usage
 Staining??
more used as maintenance therapy than active treatment
esp good for patients post periodontal therapy that have gingival recession exposure of roots- sodium flouride and chlorhexadine protect the roots from root caries

Question 7

Chlorhexidine gel

Answer 7

• Gingivitis associated with Mouthbreathing (applied on upper anterior segments-localised gingivitis due to drying out in sleep and therefore plaque accumilation )
• Use on Tepe brushes to access interproximal
  sites

(antiplaque and antibacterial properties)

Question 8

Periochip

Answer 8

 Slow release chlorhexidine from
bovine gelatin carrier
 Contains 2.5mg chlorhexidine
 Peak concentration @ 2 hours
 Continued release over 10 days
 Self-retentive in pocket
 No bacterial resistance
 ≥5mm pocket depth
 Repeat placement every 3
months

Question 9

you want to avoid surgical therapy in the upper anterior segment and instead use a non surgical approach so what do you do here

Answer 9

re instrument the root surface
insert periochip
(push it to the base of the pocket and leave it there, gelatinises when contacts blood/fluid and releases chlorhexadine locally)

Question 9

you want to avoid surgical therapy in the upper anterior segment and instead use a non surgical approach so what do you do here

Answer 9

re instrument the root surface
insert periochip
(push it to the base of the pocket and leave it there, gelatinises when contacts blood/fluid and releases chlorhexadine locally)

Question 9

you want to avoid surgical therapy in the upper anterior segment and instead use a non surgical approach so what do you do here

Answer 9

re instrument the root surface
insert periochip
(push it to the base of the pocket and leave it there, gelatinises when contacts blood/fluid and releases chlorhexadine locally)

Question 10

use of periochip

Answer 10

some use some don’t.
not a significant difference shown in effect of pocket depth reduction but some use it 3 times once post Tx once 3 months after and then 3 months after that

Question 11

Use of antimicrobial agents in
mouthwashes/toothpastes

Answer 11

(do not contain chlorhexadine most patients just use to freshen their breath)

 Quaternary ammonium compounds
Cetylpyridinium chloride (CPC)
 Triclosan
 Sanguinarine
 Metal ions: Zinc
 Oxygenating agents
Hydrogen peroxide, sodium perborate

Phenolic antiseptics: (used in lysterine)
Menthol, thymol,
Eucalyptol, essential oils

ClosSYS II active ingredient:
Chlorine dioxide
(used in chlorine dioxide)

Question 12

issue with alcohol mouthwash and why it is no longer done?

Answer 12

increased risk of oral cancer
(ethanol free lysterine is made now)

Question 13

Explain the rationale of use of antiobiotics in periodontal therapy

Answer 13

 Periodontal diseases are
infections
 The primary goal of
periodontal treatment is
the removal of sub-
gingival bacteria

Question 14

Why should you not use antiobiotics in periodontal therapy?

Answer 14

 No penetration of
antibiotics without
mechanical disruption of
the plaque biofilm
 Systemic upset
 Bacterial resistance!
 Drug availability in the
pocket?
 Non-surgical periodontal
therapy is successful
without antibiotics

Question 15

 Describe the advantages and disadvantages of systemic compared with local delivery antibiotic therapy

Answer 15

Local delivery-
Direct to site of action
* Low dosage required
* No systemic upset
* Reduced risk of
resistance
* Localised disease

Systemic-
* Access to periodontal
and other oral sites
* Cost
* Generalised disease

Question 17

Describe those conditions where local antibiotic therapy may be used in the management of periodontal diseases

Answer 17

Topical antimicrobials are used for…

 Sites showing poor response to mechanical
treatment in otherwise stable patients:
residual pocketing >5mm + BOP
 Localised molar/incisor periodontitis
 Chronic, recurrent periodontal abscesses

Question 18

Currently available local delivery antimicrobial systems?

Answer 18

 Dentomycin: 2% minocycline gel
 Atridox: 8.5% doxycycline gel
 Actisite: 25% tetracycline fibre
 Arestin: minocycline microspheres

 Elyzol: 25% metronidazole gel

 Periochip: 2.5mg chlorhexidine chip

Question 19

Dentomycin

Answer 19

 2% minocycline
hydrochloride
 Repeat placement after 14

Question 20

Atridox

Answer 20

 Active - doxycycline
 Liquid polymer, hardens
on contact with fluid
 Remains in pocket for 7
days
 Mainly used as
adjunctive therapy and in
maintenance

Question 21

Actisite

Answer 21

 Tetracycline HCl
dispersed in an
ethylene/vinyl acetate
copolymer
 Removed after 10 days

Question 22

What is periostat? not in LO

Answer 22

 Low-dose doxycycline
 sub-MIC levels
 Anti-collagenase effect
 Single dose daily over 9
months
 No bacterial resistance
problems
 Part of maintenance
programme for patients
with generalised,
aggressive periodontitis

Question 23

Write appropriate prescriptions for systemic antibiotic therapy

Answer 23

 Amoxycillin 250mg tid 5-7 days + Metronidazole
200mg tid 5-7 days
 Tetracycline 250mg qid 7 days

Periostat- single dose daily over nine months