What Is Antibiotic therapy?

Antibiotic therapy is the use of local and systemic agents to control the bacterial etiology of the inflammatory periodontal diseases. These agents include both locally and systemically delivered antibiotics and chemotherapeutic agents.

When Are Antibiotic therapy Indicated in Periodontal Therapy?

Indications for the use of antibiotic therapy in periodontal disease include the following:

• Periodontal abscess

Agressive periodontitis

Juvenile periodontitis

Rapidly progressive periodontitis

Prepubertal periodontitis

• Chronic periodontitis with persistent severe gingival inflammation

• Refractory forms of chronic or aggressive periodontitis

• Protection vs subacute bacterial endocarditis

• When surgical therapy is contraindicated

• To control local sites of inflammation

• As an adjunct to conventional mechanical therapy

• Subantimicrobial dose of doxycycline to stabilize collagenase activity

What Antibiotic therapy Are Commonly Used Systemically in Periodontal Therapy?

The most commonly used antibiotics in periodontal therapy are:

• Amoxicillin (with or without clavulanic acid – Augmentin)

• Metronidazole

• Ciprofloxacin

• Clindamycin

• Doxycycline

• Azithromycin

What Are Some of the Risks of Using Systemic Antibiotic therapy in Periodontal Therapy?

There are general and specific risks in the use of antibiotic therapy in periodontal therapy. These include:

• Allergic reactions (delayed or immediate hypersensitivity)

• Gastrointestinal problems

• Development of superinfections by unaffected organisms

• Development of resistant bacterial strains

How Is the Appropriate Antibiotic therapy Regimen Chosen?

It is preferable that the bacteria associated with the inflamed sites have been identified before the selection of antibiotic therapy. Bacterial identification may be accomplished by culturing the bacteria from within the pocket or by using DNA probe identification technology. The advantage of culturing is that sensitivity of the identified bacteria to specific antibiotics can also be reported. The major advantage of DNA probe technology is that viable bacteria are not needed to identify the penodontopathogens.

Antibiotics are prescribed without identifying the associated microorganisms and the patient is monitored for clinical success. The major risks in this approach are the selection of an antibiotic to which the pathogen is resistant or the development of a superinfection caused by an unidentified and unaffected bacterial strain.

What Are the Principles of Antibiotic therapy Dosing?

• Employ high doses for a short duration

• Use an oral antibiotic loading dose, especially with the tetracyclines or with an acute infection

• Achieve blood levels of the antibiotic at 2-8 times the minimal inhibitory concentration

• Use frequent dosing intervals, particularly with antibiotics with a relatively short half-life

• Determine the duration of therapy by the remission of disease

What Are the Potential Problems With Drug Interactions?

Depending on the mechanism of antibiotic action, combinations of antibiotics may have an additive, synergistic, or antagonistic effect Static antibiotics used in combination generally exhibit an additive effect, bacteriocidal antibiotics exhibit a synergistic effect, and the combination of bacteriocidal and bacteriostatic agents exhibit an antagonistic effect. Antibiotics may also react with other medications the patient may be taking or interact with certain foods (tetracycline chelating with calcium or other divalent cat ions). Individual drug interactions can be found in the section on specific agents below.

What Are Some Common Dosing Regimens for Systemic Antibiotic therapy Use in Periodontal Therapy?

Arriving at an appropriate antibiotic selection and dosing regimen is an inexact science. Individual antibiotics or combination therapy may be selected depending on whether or not the infection seems to be caused by one bacterial species or is a mixed infection, as most periodontal infections tend to be. Protocol selection may depend on the practitioner’s knowledge, previous experience, and perhaps by the most recent advertisement or sales representative to speak with the practitioner. The suggested regimens that follow are taken from recommendations of Dr. Thomas Rams, Director of the Oral Microbiology Testing Service at Temple University and a long-time researcher in the field of antibiotic therapy in the treatment of the periodontal diseases. While there are other suitable regimens, these recommendations are a good starting point for those practitioners in need of guidance.


Possible Antibiotic Recommendations for Specific Microbiological Test Findings

*For combinations of anaerobic and facultative periodontal pathogens:

1st choice: Metronidazole + amoxicillin or Augmentin@ (250 mg each TID for 5-7 days, or metronidazole 500 mg and Augmentin 875 mg each BID for 5-7 days)

2nd choice: Metronidazole ÷ ciprofloxacin (500 mg each BID for 5-7 days)

Note: Combination drug regimens are generally preferred to single antibiotic administration)

For Actinobacillus actinomycetemcomitans:

1st choice: Metronidazole + amoxicillin or Augmentin (250 mg each TID for 5-7 days, or metronidazole 500 mg and Augmentin 875 mg each BID for 5-7 days)

2nd choice: Ciprofloxacin (adults only) alone or with metronidazole (500 mg each BID for 5-7 days)

3rd choice: Azithromycin (500 mg/day for 3-5 days)

4th choice: Doxycycline (100 mg BID for 14-21 days)

*For anaerobic pathogens (Porphyromonas gingivalis, Prevotella intermedia, Sacteroides forsythus, Fusobacterium species, Peptostreptococcus micros, and Campylobacter species):

1st choice: Metronidazole + amoxicillin or Augmentin (250 mg each TID for 5-7 days, or metronidazole 500 mg and Augmentin (875 mg BID for 5-7 days)

2nd choice: Augmentin® (250-500 mg TID, or 875 mg BID for 7 days)

3rd choice: Metronidazole (500 mg BID for 7 days)

4th choice: Clindamycin (150 mg TID for 5-7 days)

5th choice: Azithromycin (500 mg/day for 3-5 days)

6th choice: Doxycycline (100 mg BID for 14-21 days)

(Note: Some Fusobacterium strains may metabolize metronidazole and reduce its efficacy; some Pepto- streptococcus micros strains are resistant to tetracydines, metronidazole, and azithromycin; Prevotella intermedia is often resistant to tetracycline antibiotics.)

*For enteric rods, Pseudomonads, Enterococci and/or Staphylococci:

1st choice: Ciprofloxacin (usually given with metronidazole – 500 mg each BID for 5-7 days)

2nd choice: Variable depending on strain susceptibility

*For beta-hemolytic Streptococci:

1st choice: Augmentin(250-500 mg TID or 875 mg BID for 7 days)

2nd choice: Clindamycin (150 mg TID for 5-7 days)

What Are Some Common Reasons for Antibiotic therapy Failure in Periodontal Therapy?

• Inappropriate choice of antibiotics (the microorganism is not susceptible to the antibiotic of choice)

• Incorrect / inadequate doses

• Emergence of antibiotic-resistant microorganisms

• Too low a blood concentration of the antibiotic

• Slow growth rate of the microorganisms

• Impaired host defenses

• Patient noncompliance

• Antibiotic antagonism (eg, using bacteriocidal and bacteriostatic antibiotics together)

• Inability of the antibiotic to penetrate to the site of infection

• Limited vascularity or decreased blood flow

• Unfavorable local factors

• Failure to eradicate the source of infection

What Is Subantimicrobial Antibiotic therapy Usage?

It has been demonstrated that tetracycline and the tetracycline derivative doxycycline (subantimicrobial dose of doxycycline – SDD) can reduce collagenase activity when used in doses too low to have any antimicrobial effect. The use of SDD has been shown to reduce the rate and amount of attachment loss associated with advancing periodontal disease. SDD is currently used as a 20 mg dose of doxycycline twice a day. Long-term studies have been for 9-month durations. There is little data on the manufacturers provide detailed instructions, there is an effectiveness of SOD therapy for longer periods of time, the learning curve to developing an efficient technique for the use of each product.

What Are the Indications for the Use of Locally Delivered Antibiotic therapy and Antimicrobial Therapy?

• Local site(s) with signs of inflammation that have not responded to conventional mechanical therapy

• Local site that has recurrent signs of inflammation at a maintenance visit

• Buying time for a so-called hopeless tooth before extraction

• Resolving marginal inflammation when oral hygiene has reached maximum effectiveness distributors.

What Therapeutic Mouthrinses Are Available to Reduce Plaque and Help Control Gingival Inflammation?

It should be remembered that a mouthrinse must not only reduce plaque but also have a therapeutic effect.

Currently; long-term antibiotic therapy like, 6-month studies support only the use of mouthrinses containing 0.12% chlorhexidine gluconate or the “essential oils” (phenolic compounds – thymol, menthol, eucalyptol, methyl salicylate) to reduce plaque and gingivitis. These mouthrinses are available to consumers through a variety of manufacturers. These mouthrinses must be used appropriately usually a 30-second rinse twice daily to be effective These rinses have an alcohol vehicle ranging from 17% to 26.7%.

What Are Other Periodontal Conditions That May Require Chemotherapeutic Treatment along with Antibiotic therapy ?

• Vesiculobullous diseases

— Benign mucous membrane (pemphigous)

— Lichen planus

— Pemphigus vulgaris

• Viral infections

— Herpes simplex

— Human immunodeficiency virus

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