SYSTEMIC ANTIBIOTICS & PERIDONTAL TREATMENT
Periodontitis
is an infective disease process. One of the most important recent enhancements
to our knowledge of the nature of the infective process has been identification
of probable periodontal pathogens. Based on the criteria of association
with disease progression, disease remission following elimination, immune
system responses and virulence factors, the following bacteria have been
implicated as potentially perio-pathogenic microorganisms: |
Gram-negative obligate
anaerobes
P.gingivalis - P.intermedia
- B.forsythus - Fusobacterium sp. - Selenomonas sp. - spirochetes
Gram-negative faculative
anaerobes
A.actinomycetemcomitans
- Campylobacter rectus - Eikenella corrodens
Gram-positive obligate
anaerobes
Peptostreptococcus micros
- Eubacterium sp.
Periodontal therapy
aims to eliminate the potentially pathogenic microorganisms, allowing the
residual pockets to be colonised by species of bacteria that are not associated
with disease activity (commonly referred to as beneficial species). These
bacteria include Veillonella parvula, Actinomyces sp., Streptoccus oralis,
Streptococcus mitis and Capnoctyphaga ochracea. For the vast majority
of patients, mechanical removal of subgingival plaque and calculus, coupled
with excellent supragingival plaque control, will halt the loss of periodontal
attachment. However, some patients will continue to exhibit inflammation,
as evident through bleeding on probing, and continued loss of` attachment
at one or more sites in their mouth. It is at this stage that the use of
antibiotics as an adjunct to further periodontal therapy is sometimes considered.
The decision to use
antibiotics must be based upon a knowledge of the likely bacteria to be
causing the problems. As the bacteria involved are usually anaerobes, culturing
of plaque samples is very difficult and expensive. DNA probe techniques
are being developed to identify a range of bacteria, but at this stage
their availability for use in a general practice setting is limited. Therefore,
the choice of antibiotic to be used is usually based upon the findings
of clinical trials reported in the literature, as well as taking into account
the form of periodontitis experienced by the patient, and any modifying
medical conditions.
Acute Necrotizing Ulcerative
Gingivitis
A suggested approach to the
management of this painful condition is:
1) gentle debridement to
remove plaque and debris;
2) prescription of chlorhexedine
and an oxygenating mouthwash;
3) prescription of Flagyl
(metronidazole) 200mg, three times a day for seven days;
4) review after three to
seven days to begin periodontal therapy.
If you suspect compliance
problems with the patient taking a course of antibiotics, the prescription
of Tinidazole (Fasigyn) 2 grams stat is as effective as Flagyl. Giving
the patient 4 x 500mg tablets at chairside overcomes any compliance problems
and provides adequate blood levels for 2 to 3 days at which time the patient
may be reviewed.
The prescription of
an antibiotic seems to reduce the pain associated with ANUG more quickly
than debridement plus mouthwash alone.
Juvenile Periodontitis
The facultative anaerobic
bacteria, Actinobacillus actinomycetemcomitans (or A.a), is the predominate
cultivable bacteria associated with this type of disease. While non-surgical
or surgical debridement of affected sites may eliminate this bacteria and
lead to resolution, it appears that antibiotics as art adjunct to debridement
provide a more predictable long term result for many patients. The antibiotic
of choice for these patients is doxycycline, 100mff once a day for 21 days
Rapidly Progressive Periodontitis
Many cases of rapidly
progressive periodontitis stabilise after the affected sites are thoroughly
debrided, effective oral hygiene is established and maintenance therapy
is performed regularly. However, some patients continue to show loss of
attachment in spite of these factors. Others will experience the occurrence
of one or more periodontal abscesses after treatment. In these situations,
the decision to use antibiotics as an adjunct to further root debridement
is justified.
From the literature,
a two week course of doxycyline (100 mg, once a day), along with surgical
or non-surgical debridement, can lead to stabilisation of the disease process.
However, it appears that tetracycline- resistant strains of pathogenic
bacteria are beginning to emerge, and hence some patients will respond
better to a combined course of amoxycillin (250 mg three times a day) and
rnetronidazole (200 rng, t.i.d.) for seven days. It is important to realise
that amoxycillin alone is ineffective in controlling periodontal infections,
and therefore should not be prescribed. Similarly, because many periodontal
pathogens secrete beta-lactamase (which makes them resistant to penicillins),
penicillins are inappropriate for the management of periodontal infections.
Adult-type Periodontitis
Adult-type periodontitis
should respond in a predictable way to thorough non-surgical root debridement
and excellent plaque control. If sites continue to break down in spite
of this approach, then surgery to gain access to sites that may have been
difficult to clean is the next treatment of choice. No additional antibiotic
therapy should be necessary for this procedure.
Antibiotic cover for
periodontal procedures in patients with medical conditions
The prevention of
infective endocarditis due to bacteraemia arising from periodontal treatment
is essential. Any procedure that induces gingival bleeding can result in
a bacteraemia, and hence patients at risk must be protected by antibiotic
cover for periodontal probing, scaling and root-planing, and periodontal
surgery. It is important for dentists to remain up to date with current
recommendations.
There are a number
of guidelines available from various medical authorities, and these may
differ slightly in their recommendations. It is essential for dentists
to discuss any proposed dental treatment with the patient's cardiologist
for advice regarding the selection of the most appropriate antibiotic regime
The most up-to-date
overview of microbiological aspects of periodontal diseases can be found
in the journal Periodontology 2000, Volume 5, 1994. This volume, titled
Microbiology and immunology of periodontal diseases, includes a
chapter on on antimicrobial strategies for treatment of periodontal diseases
written by J. Max Goodson.
This material has
been compiled with the assistance of Dr Louise Brown, Lecturer in Periodontics
at the University of Melbourne.
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