1

ANTI-INFECTIVE
THERAPY
Bethel ,DMD
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DEFINITIONS
Chemotherapeutic agent: acts to reduce the
number of bacteria present.

Antibiotic: naturally occuring semisynthetic or

synthetic type of anti-infective agent.

Antiseptic: a chemical antimicrobial agent

applied topically or subgingivally.
 3

ROUTE OF
ADMINISTRATION
Systemic: may be a necessary adjunct in controlling
bacterial infection.

Local: directly into the pocket has a potential to

provide greater concentrations.

A single agent can have a dual mechanism of action

(tetracyclines)
 4

SYSTEMIC ADMINISTRATION
OF ANTIBIOTICS
Treatment of periodontal disease is based on
infectious nature of the disease.
An ideal antibiotic for use in prevention and
treatment of periodontal disease:
1. Specific for perio. pathogens.
2. Nontoxic.
3. Inexpensive.
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SYSTEMIC ADMINISTRATION
OF ANTIBIOTICS
The treatment of the individual patient is based on:
1. Patients clinical status.
2. Nature of colonizing bacteria.
3. Ability of the agent to reach the site of infection.
4. Risks and benefits associated with the proposed
treatment.
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SYSTEMIC ADMINISTRATION
The clinician is OF ANTIBIOTICS
responsible for choosing the
correct antimicrobial agent.
Some adverse reactions include:
1. Allergic/anaphylactic reactions.
2. Superinfections of opportunistic bacteria.
3. Development of resistant bacteria.
4. Interaction with other medications.
5. Upset stomach.
6. Nausea.
7. Vomiting.
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TETRACYCLINES:

Used widely in perio.disease treatment.

Used frequently in treatment of refractory periodontitis
and LAP.
Has the ability to concentrate in the periodontal tissue
and inhibit the growth of Aggregatibacter
actinomycetemcomitans.
Exert an anticollagenase effect that can
inhibit bone destruction and may aid bone
regeneration.
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TETRACYCLINES:
Bacteriostatic.effective against rapidly multiplying
bacteria.
G+ve>>G-ve bacteria.
Concentration in gingival crevice 2-10 times in serum.
Long term regimens can develop resistant bacteria.
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TETRACYCLINE HCL
Administration 250mg 4 times daily (qid).
Inexpensive
Side effects: GI disturbances, photosensitivity, blood
urea nitrogen, tooth discoloration.
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MINOCYCLINE
Suppresses spirochetes and motile rods.
Given 200 mg/day for 1 week.
Less photosensitivity and renal toxicity.
Side effects: are similar to those of tetracycline
however there is increased incidence in
vertigo.
Only tetracycline that can discolor
permanently erupted teeth and gingival tissue
when administered orally.
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DOXYCYCLINE

Has same spectrum as minocycline,but only given

once daily(qd) more compliant!!
Most Photosensitizing Agent In Tetracyclines.
DOSES:
1. Antiinfective agent; 100mg bid 100mg qd or 50mg bid .
2. Sub antimicrobial (inhibit collagenase) 20 mg twice
daily.
3. Periostat!!
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METRONIDAZOLE
Nitroimidazole compound developed for protozoal
infection.
Bactericidal to anaerobic organisms because it disrupts
the bacterial DNA.
Effective against P.g and P.i but not the drug of choice
against A.a unless combined to other antibiotics!!!!
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Used to treat:
METRONIDAZOLE
1. Gingivitis.
2. Necrotizing ulcerative gingivitis/ NUG
3. Chronic periodontitis/CP
4. Aggressive periodontitis/AP
Doses:
1. 250mg 3 times daily(tid) for a week.
2. Arestien.(local delivery sustained release
form).
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METRONIDAZOLE
Side effects:
1. Antabuse effect when alcohal is ingested.
2. Inhibits warfarin metabolism.
3. Patient on anticoagulant should avoid it. b/c
prolongs prothrombin time.
4. Should be avoided in patients on lithium.
5. Metallic taste in mouth
 15

PENICILLINS
Most widely used antibiotic.
Inhibit bacterial cell wall production and so they are
bactericidal.
Induce allergic reactions and bacterial resistance.
Amoxicillin and amoxicillin-clavulanate potassium
(Augmentin).
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PENICILLINS
Amoxicillin is semisynthetic penicillin with extended
antiinfective spectrum (G+ve,G-ve)
Amoxicillin is for treatment of aggressive periodontitis
both localized and generalized forms.
Augmentin is used for management of LAP or refractory
periodontitis.
Amoxicillin: AP (LAP & GAP)
Augmentin: LAP or refractory periodontitis
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CEPHALOSPORINS
Are not used for treatment of dental disease.

Patients allergic to penicillin are allergic to

cephalosporins.
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CLINDAMYCIN
Effective against anaerobic bacteria with strong affinity
for osseous tissue.
For penicillin allergic patients.
Efficacy to periodontitis refractory to tetracycline
therapy.
DOSES: 150mg (qid) for 10 days.
300mg(bid) for 8 days.
Associated with pseudomembranous colitis.
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CIPROFLOXACIN
A quinolone active against gram negative rods (all
facultative, some anaerobic putative periodontal
pathogens).
Ciprofloxacin therapy may facilitate establishment of a
microflora associated with periodontal health.
ONLY antibiotic that all strains of A.a are susceptible.
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CIPROFLOXACIN
Side effects:
metallic taste,
inhibit the metabolism of theophylline and caffeine.
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MACROLIDS
Inhibit protien synthesis, bacteriostatic or bactericidal
depending on drug concentration.
Macrolids used in periodontal treatment include
erythromycin, spiramycin, and azithromycin.
DOSES: Therapeutic doses of 250mg/day for 5 days
after an initial loading dose of 500mg.
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MACROLIDS
DID YOU KNOW.
Erythromycin is not concentrated in GCF, spiramycin is
excreted in high concentration in saliva and it has
been proposed that azithromycin penetrates fibroblasts
and phagocytes in concentrations 100-200 times
greater than extacellular compartment!!!
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SERIAL AND COMBINATION

ANTIBIOTIC THERAPY
Periodontitis is a mixed infection, in this condition
treatment requires more than one antibiotic serially or in
combination!!!!!
Bacteriostatic drugs require rapidly dividing
microorganisms, they do not function well with
bactericidal antibiotics!!!!
If both types are required then it is best to use them
serially not in combination.
SERIAL AND COMBINATION 24

ANTIBIOTIC THERAPY

Bacteriostatic Bactericidal
Erythromycin Penicillin
Tetracycline Cephalosporin
Clindamycin Vancomycin
Metronidazole
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GUIDELINES FOR
ANTIBIOTICS IN
PERIODONTAL THERAPY
1. Clinical diagnosis and situation dictate the need for
ABC therapy.
2. Disease activity, measured by continuing attachment
loss, purulent exudates
3. Patient medical and dental status and current
medication.
4. Microbiological plaque sampling.
5. Identification of which antibiotics were most
effective
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LOCAL DELIVERY AGENTS

Subgingival chlorhexidine .
Tetracycline containing fiber.
Subgingival doxycycline.
Subgingival minocycline.
Subgingival metronidazole.
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SUBGINGIVAL
CHLORHEXIDINE
A resorbable delivery system.
Biodegradable system that resorbs in 7-10 days.
Perio Chip is a small chip (4.0 5.0 0.35 mm).
 TETRACYCLINE CONTAINING 28

FIBER (ACTISITE)
consists of a polymer ethylene vinyl acetate
containing 25% of saturated tetracycline HCl. It is
marketed in the length of 23 cms and 0.5 mm diameter
containing 2.7 mg of tetracycline HCl
It was well tolerated in oral tissues and concentrations
reach 1300g/ml
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SUBGINGIVAL
DOXYCYCLINE
A gel system using a syringe with 10% doxycycline
(Atridox).
 SUBGINGIVAL
30

MINOCYCLINE(ARESTIN).

A locally delivered sustained release form of

minocycline microspheres .The 2% minocycline is
encapsulated into bioresorbable microspheres in gel
carrier.
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SUBGINGIVAL
METRONIDAZOLE
A topical medication containing an oil based
metronidazole 25% dental gel.
Two 25% gel application at a 1-week interval have
been used.
Bleeding on probing was reduced by 88% of cases.
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CONCLUSIONS
Scaling and root planing are effective in reducing
pocket depths.
When systemic antibiotics are used as adjuncts to
scaling and root planing the evidence indicate that
some antibiotics provide additional improvement.
There are extensive reviews of the local delivery agents
available for periodontitis.
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CHEMICAL ANTIPLAQUE AGENTS

The chemical preventive agents should be used as
adjuncts and not as the replacements for the more
conventional and accepted effective mechanical
methods.
The action of chemical antiplaque agent can be
categorized into
i. Anti adhesive
ii. Antimicrobial
iii. Established plaque removal
iv. Anti pathogenic
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Ideal Properties of a Mouthwash should

1. Eliminate pathogenic microorganisms only.

2. Prevent development of resistant bacteria.
3. Exhibit substantivity.
4. Be safe to oral tissues at the recommended concentration.
5. Significantly reduce plaque formation and gingivitis.
6. Inhibit calcification of plaque to calculus.
7. Not stain and alter taste.
8. Not have adverse effects on teeth or dental materials.
9. Be easy to use.
10. Be inexpensive
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Chlorhexidine (CHX)
chlorhexidine was first investigated by Schroeder in 1969
is available in three forms,
the - digluconate,
- acetate
- hydrochloride salts
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Mechanism of Action
I. Antibacterial activity: chlorhexidine is rapidly attracted
to the negatively charged bacterial cell surface, with
specific and strong adsorption to phosphate containing
compounds.
II. Antiplaque activity
i. It blocks the acidic groups on the salivary glycoproteins
thus, inhibit pellicle formation.
ii. It directly binds to the bacterial surface in sublethal
amounts and thus, prevents the adsorption of bacteria
onto tooth surface.
iii. It inhibits acid production in established plaque
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Clinical uses of chlorhexidine are:

i. Presurgical preparation of periodontal patients

ii. Postoral surgery including periodontal surgery/
root planing
iii. In patients with jaw fixation
iv. Medically compromised patients predisposed to
oral infections
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v. Mentally and physically handicapped patients

vi. High caries risk patients
vii. Recurrent oral ulceration
viii. Removable and fixed orthodontic appliance
wearers
ix. In the denture stomatitis patients
x. Preoperative rinsing during ultrasonic scaling and
polishing with high speed instruments
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Adverse effects:
i. Staining: Brown discoloration of teeth, restoration
and dorsum of tongue. The various proposed
mechanism of chlorhexidine staining are:
Degradation of chlorhexidine molecule to release
parachloraniline
Precipitation of anionic dietary chromogens
Protein denaturation with metal sulfide formation
Catalysis of Maillard reactions
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ii. Taste alterationInterference with taste sensation is

probably caused by denaturation of surface proteins on
the taste buds.
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Quarternary Ammonium Compounds

They are cationic surface active agents that act
by rupturing cell walls.
Cetylpyridinium chloride has been widely used as
mouthrinses at a concentration of 0.05%,
Cetylpyridinium chloride molecule has both
hydrophilic and hydrophobic interactions.
The substantivity appears to be only 3-5 hours
 43

Listerine
It is phenol related essential oils consisting of
thymol (0.064%), eucalyptol (0.092%), methanol
(0.042%), methyl salicylate (0.060%) in
hydrochloride solution and benzoic acid (0.15%).
The advantages of listerine are that there is no
taste alteration or staining as seen with
chlorhexidine usage.
It is less expensive and is easier to obtain than
chlorhexidine, as it is sold over the counter.
 44

The disadvantage of Listerine is its high alcohol

concentration (ranging from 21.6 to 26.9%) which,
may exacerbate xerostomia.
The alcohol is added in mouthrinses to solubilize
antimicrobial compound in order to make them
bioavailable and
to improve the shelf-life of the mouthrinse and
to some extent improve the pleasurable
characteristic of mouthrinsing.
 45

Peroxide
is an antiseptic agent that is toxic to many bacteria
because of its strongly oxidizing properties.
The critical factor in peroxide activity is the fact that
H2O2 and other reduction products of O2 (superoxide
anions) can generate the more toxic hydroxyl radicals.
These reactive O2 species

damage cell membranes,

inactivate bacterial enzymes via oxidation of sulfahydryl
group and,
disrupts bacterial chromosome and
destroys the bactericidal action of myeloperoxidase
enzyme.
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disadvantage
it is toxic to the host, causing peroxidation
of lipids in cell membrane and certain
chromosomal changes.
 47

Triclosan

act on the microbial cytoplasmic membrane causing

leakage of cellular constitutents and thereby, causing
bacteriolysis.
the hydrophobic portion of the triclosan molecule
adsorbs to the lipid portion of the bacterial cell
membrane functions.
It is bacteriostatic at low concentration and
bacteriocidal at high concentration.
Substantivity period of approximately 5 hours.
 48

Advantages:
No staining
Can inhibit several important mediators of gingival
inflammation
It has dual effect both as an antibacterial and anti
inflammatory
 49

Povidone Iodine
consists of iodine plus a solubilizing agent, i.e.
polyvinylpyrrolidone (povidone)
is microbiocidal for G+ve and G-ve bacteria, fungi,
mycobacteria, viruses and protozoans.
Its bacterial activity is due to oxidation of amino,
thiol and hydroxyl groups
The substantivity of povidone iodine is around 60
minutes.
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PVP-1 reacts strongly with double bonds of unsaturated

fatty acids in cell walls and organelle membranes. Thus,
causing transient or permanent pore formation which
results in loss of cytoplasmic material and deactivation
of enzymes due to direct contact with iodine.
 51

contraindicated in pregnant women, nursing mothers

and in those who are allergic to iodine.
Side effects of povidone iodine are staining of teeth
and surrounding tissues
 52

Natural Products
Sanguinarine
The trade name of Sanguinarine prouct is Viadent.
It is antimicrobial agent effective against gram-
positive and gram-negative bacteria.
it seems to interfere with essential steps in the
synthesis of bacterial cell wall. It suppresses the
activity of several enzymes.
Propolis It is used as plaque inhibitory mouthwash
because of its antiseptic, antiinflammatory and
bacteriostatic property
AGE CHANGES IN
PERIODONTAL
TISSUES
 AGE CHANGES IN
PERIODONTAL TISSUES
All tissues under go certain changes as result of aging
Manifestations
1.Reduction in vascularity
2.Reparative capacity
3.Atrophy (senile atrophy )
e.g. with aging recession of gingiva and alveolar
bone resorption occur
 FIG. MEASUREMENT OF PROBING DEPTH. NOTE
THE GINGIVAL
RECESSION AT THE BUCCAL ASPECT OF TEETH 21
AND 22.
RADIO GRAPHICALLY
 CONTI
Greater prevalence of periodontal disease as age
advances is seen
As result of aging increased arteriosclerotic changes
occur
The width of periodontal ligament is generally reduced
as result of continous deposition of cementum & bone
FURCUSSION
 CONTI
Reduction in masticatory function may also contribute
to narrowing of ligament space with age
Osteoporosis , decreased vascularity & gradual
reduction in metabolic rate have been reported in
alveolar bone with increased aging ,despite significant
age changes the residual periosteal & end steal cells
of alveolar bone seem capable of responding to
fuctional forces as well as trauma.
 CONTI.
Cementum formation is continuous throughout life
cellular cementum is deposited in apical third of roots
to componsate for attrition (occlusal ,proximal area).
The arch length is believed to be reduced by o.5 cm by
age of 40.
 CONTI.
Gradual reduction in gingival keratinization cellularity of
connective tissues & O2 tension have been reported in
gingiva as result of aging .
The oral epithelium appears thinner with age in most
cases
The width of attached gingiva increase with age
Number of elastic fibers in periodontal ligament has been
shown to increase with age & also decreased vascularity.
 62

In comparison, older adults with no history of gingivitis

displaying overall healthy oral conditions show an
increased number of gram-negative bacteria directly
related to inflammatory responses
Several of these gram-negative bacteria are associated
with gingivitis and periodontitis including P. gingivalis and
Fusobacterium nucleatum.
The presence of these anaerobes in older adults is
believed to be a result of aging and the bodys natural
decline in immune responses leading to a greater
susceptibility to periodontal disease.
 63

Periodontal Treatment Planning

The goal of clinically managing periodontal disease in
older adults is based on specific, individualized care.
The major consideration is improving or maintaining
function, with an emphasis on quality-of-life issues.
Several factors must be considered during treatment
planning for older individuals.
 64

It is important first to remember that periodontal healing

and recurrence of disease are not influenced by age.
Factors to consider in the older patient are medical
and mental health status, medications, functional
status, and lifestyle
behaviors that influence periodontal treatment,
outcome, or progression of disease
 65

For older adults, a nonsurgical approach is often the

first treatment choice.
Depending on the nature and extent of periodontal
disease, surgical therapy may be indicated.
Age alone is not a contraindication to surgery.
A common goal for all older adults is to decrease
bacteria through oral hygiene and mechanical
debridement.
 66

Prevention of Periodontal Disease and Maintenance

of Periodontal Health in Older Adults
For both younger and older persons, the most
important factors determining a successful
outcome of periodontal treatment are plaque
control and frequency of professional care.
however, older adults may have difficulty
performing adequate oral hygiene because of
compromised health, altered mental status,
medications, or altered mobility and dexterity.
 67

In addition, Assessments of overall health, functional

status, and patient education are fundamental to
promoting and maintaining optimum periodontal
health.
 PREVENTION OF PERIODONTAL DISEASE 68

AND MAINTENANCE OF PERIODONTAL

HEALTH IN OLDER ADULTS

Chemotherapeutic Agents
Antiplaque Agents
Fluoride