مطر عالء

Nicola

21

30/3/2015

Periodontics

Lecture No.

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University of JordanFaculty of Dentistry

Fourth year –2nd semester 2014-2015

1 refractory periodontal disease: not amenable to treatment no matter what measures we do i.e. scaling, polishing, root planning, OHI we still fail to manage this disease .

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Antiseptics and Antimicrobials in Periodontology This lecture is going to discuss antiseptic and antimicrobial agents used in periodontology; their properties, the criteria that classify them and multiple examples on these agents and their uses, names and properties.

It is believed in periodontology that 90% of the diseases caused by bacteria can be treated by the removal of the cause only without the need for antiseptic or antimicrobial agents. Most of gingivitis and periodontitis cases are treated by the removal of the cause i.e. teeth brushing only where the complications of using antimicrobial agents are avoided. On the other hand, there are certain indications for the use of supplemental antimicrobial therapy "e.g. aggressive periodontitis, acute necrotizing ulcerative gingivitis, draining abscess", in these cases antibiotic supplement is needed in addition to the removal of the cause. For each disease a specific type of antimicrobial agent is used, and in periodontal diseases the antibiotic used should be specific for bacterial plaque.

Evaluation of antimicrobial agents: there are some properties of good antiseptic and antimicrobial agents, these criteria if present they would eliminate 100% of bacteria which is impossible but we should know them in order to evaluate the effectiveness of the agent we are using. These properties are:

1) Specificity: Antimicrobial substances reserved for the treatment of serious medical infections must as a role not be used to control plaque locally. Systematically administered antibiotics may be used in rare situations in patients with aggressive and refractory1 forms of periodontal diseases, but only after proper periodontal diagnosis. According to this we administer antibiotics for serious conditions only and not for every single case of periodontal disease as this is common in our culture, for most of gingivitis and periodontitis cases we don’t prescribe any antimicrobial agent at all and we prescribe them only for certain serious conditions.

*Never prescribe an antimicrobial agent to eliminate plaque locally as this is ineffective.

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2) Efficacy: The antimicrobial agent selected must be effective against microorganisms implicated in the etiology of gingivitis and periodontitis. The plaque that causes gingivitis and periodontitis contain more than 300 species of bacteria, and there is no chance to eliminate all these types of bacteria using single medication, so it is waste to prescribe an antimicrobial agent to eliminate the plaque locally.

3) Substantivity: Is a measure of the contact time that connects a substance and a substrate in a given medium. There are two properties of the substance you should differentiate between them: Absorption and adsorption, absorption is when one substance enters completely into another e.g. a sponge absorbs water molecules, while adsorption is when the molecules of one substance adhere to the surface of the adsorbent substance and this what we mean by substantivity. In order for an antimicrobial or antiseptic agent to be effective it should be able to adhere to the surface of the microbe "substantivity". Agents with anionic effect have transient action while agents with cationic effect have substantivity.

Till the moment none of the antimicrobial agents available nowadays posses the first two properties, while for the third one they've manufactured a material that posses substantivity effect.

Aims: we have certain goals in manufacturing antiseptic and antimicrobial agent:

1) Should inhibit microbial colonization of the tooth surface and subsequent development of plaque. Till this moment they haven’t manufacture an antimicrobial or antiseptic agent that reduces bacteria by 100% and inhibit colonization of the tooth surface. Many of the available agents have transient effect and can reduce bacterial plaque by up to 90%, but none of these has succeeded to eliminate bacterial plaque completely.

2) Should eliminate plaque already present by dissolution or alteration to form less pathologic plaque. Unfortunately none of the antimicrobial and antiseptic agents available has succeeded to dissolve or eliminate the plaque already present in the oral cavity.

3) Should inhibit the calcification of the plaque to form calculus. Till the moment there is no agent or drug available that can inhibit the transformation of plaque into calculus .

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Limitations: There are some limitations for our aims that prevent us from manufacturing antiseptic and antimicrobial agents that posse the criteria we desire:

1) Only transient effect while they are in the oral cavity. These agents have anionic effect only and they don’t adsorb to the microbe surface e.g. mouthwashes kills bacteria only on contact as long as the agent is in the mouth, once we spit it the effect disappear as these agents lack substantivity.

2) Some are of insufficient concentration to kill bacteria and if their concentration is increased they damage epithelial cells. Different types of antiseptic and antimicrobial agents are available by different concentrations depending on their MIC-minimum inhibitory concentration. If a patient can be treated with 250 mg of certain agent increasing the concentration will only damage the epithelium with no benefit of the increased dose. A good example is Aspirin that was available as 175 mg tables, few years ago this dose was decreased to 100 mg " Baby Aspirin " because they discovered that this dose is sufficient to do the job and no need for increasing the concentration while causing chemical damage to the body.

3) Mouthwashes are only of use on supragingival plaque and therefore for preventing and controlling gingivitis in risk patients e.g. post surgery, handicapped, mucosal conditions "erosive/ulcerative" and prior to ultrasonic scaling. All the types of mouthwashes available nowadays are only effective against supragingival plaque and none of them can penetrate subgingivally and therefore are effective only for gingivitis but not for periodontitis. Oral irrigators are devices used to irrigate the oral cavity with water. In these devices we can put an antiseptic agent in the container and mix it with the water in order to increase the effectiveness of the irrigation, this type of irrigation can penetrate into subgingival spaces and therefore it is an exception, but for 99% of mouthwashes use the agent will not penetrate subgingivally. Antiseptic agents are not indicated for daily use and are used only with risk patients. Prior to ultrasonic scaling we use a mouthwash for 1 minute before scaling with ultrasonic devices as this reduces bacterial count by 70% because ultrasonic scaling produces aerosols that disperse the bacteria in the oral cavity and spread the disease. Mouthwashes and similar agents are not substitutive for brushing and are called adjunctive measures. Scientifically mouthwashes are only intended to use on prescription for certain cases.

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ANTISEPTICSEnzyme preparations: preparations of antiseptic agents as mouthwashes:

1) First generation compounds.2) Second generation compounds.

1) Phenol-based preparations:

Listerine: Is a first generation antiseptic mouthwash, one of the best mouthwashes available. In USA Listerine was used as a substitute to alcoholic drinks and there is a high percentages of people who addicted on Listerine as it contain high concentration of alcohol i.e. 20% alcohol compared with the other alcohol beverages that contain between 2-10% alcohol. Recently Listerine-zero was introduced, this preparation doesn’t contain alcohol but it is expensive. Listerine mouthwash has a transient anionic effect and it is effective as long as in the oral cavity and after spitting the effect disappears. Listerine is a counter item that can be bought without prescription. This agent can be used for multiple times daily as many as you want and in every time a 20 ml of the mouthwash is used for 1 minute. We shouldn’t use a volume higher than 20 ml because this agent contains sodium lauryl sulphate which is the essential component of soap that produces the foam, if large volume is used you will not be able to hold the liquid in your mouth and control it but instead you will spit it after few seconds because of the abundant foam. Listerine was shown clinically to reduce plaque scores by 20% and gingivitis by 30% and thought to reduce plaque pathogenicity by decreasing endotoxin activity.

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2) Bisguanides: The most effective anti-plaque family and the main second generation anti-plaque agent, one of the best and the best mouthwash available. The structure of this agent is made of two chains together that forms the chains chemically.

Chlorhexidine Gluconate: Abbreviated as CHX or CXD. Purely topical action so this agent doesn’t penetrate oral mucosa "doesn’t absorb" but instead it has the property of adsorption on the surface of tissues and it is safe. Poorly absorbed systemically because after spitting the agent the number of residues doesn’t cause toxicity. Levels up to 0.2% are tolerated by the eye and safe to the skin, a concentration higher than 0.2% causes deafness if it is instilled in the ear, if it is instilled in the eye it causes blindness. Regardless of the concentration of the mouthwash used the patient should never use it while the head is tilted backwards because an aerosol will get out the mouth and come in contact with the eye. The most effective anti-plaque agent to date. CXD adsorbs epithelium and tooth surfaces and may reduce bacterial binding to tooth tissues. CXD should be used for 1 minute every time, if less than that the effectiveness will decrease as there is no adsorption. The patient should be advised not to use the tooth paste and the mouthwash together, but instead there should be a delay of 30 minutes between them because the mouthwash is cationic and the detergents in the toothpaste are anionic, anionic and cationic components inactivate each other, by inactivation the CXD loses the property of adsorption. CXD is the only mouthwash that has adsorption effect as it is cationic agent. In the absence of other oral hygiene measures CXD reduces oral bacterial count by 85-90%. The minimum concentration of CXD to be effective as plaque inhibitor is 0.12%. As opposed to other antiseptic agents CXD has an adsorption effect and thus can be retained in the oral cavity for 12 hours and it is recommended to be used 2times daily.

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Chlorhexidine has some unwanted effects:

Extrinsic staining : CXD is the only mouthwash that causes staining of the teeth but this is staining is reversible after polishing the teeth surfaces.

Desquemative gingivitis: Shedding of epithelium; a type of hypersensitivity to CXD in rare cases leads to erosions of gingiva and burning sensation, but this effect is reversible once the patient stops using this agent.

Altered taste sensation particularly to salty tastes, where the patient feels metallic taste, but it is a short term effect.

Parotid swilling is a very rare complication "1 in million"; which is a bilateral and reversibly swelling of parotid glands.

Chlorhexidine shouldn’t be prescribed for every patient as there are certain indications for its use: Post surgical, handicapped patients, patients wearing orthodontic appliances and have gingival enlargement. Any other mouthwash can be used daily for life, while for CXD it shouldn’t be used for more than two weeks, and after stopping the usage of this agent all the previously mentioned complications will start to disappear.

Chlorhexidine uses:

* Post-surgery .

* Severely impaired cognitive skills e.g. Down syndrome.

* Handicapped patients.

* Ulcerative gingival conditions e.g. aphthous ulcer.

Chlorhexidine brand names :

1) CORSODYL 0.2%.

2) ELUDRIL.

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مطر Perio #2130/3/2015عالء3)PLAX: This mouthwash has no effect at all as it contains glycerine only.

4)Hexedine: Another group of mouthwashes, it is totally different from CXD. Its commercial name is Oraldene, one of the best mouthwashes available that is very effective.

ANTIBIOTICS Indications of antibiotic usage:

1) Refractory periodontitis.

2) Necrotizing ulcerative gingivitis.

3) HIVP; P stands for periodontitis associated with AIDS.

4) As a prophylactic measure, particularly in case of prosthetic heart valve.

5) Multiple abscess formation as diabetic patients.

In dentistry antibiotics are administered by two routes only:

1) Systemic: IV, IM, tablets.

2) Local: The antibiotic drug is produced in the form of microchips that have the property of sustained release; the microchip is inserted into the pocket and during the first day 50% of its contents are released and during the next two weeks the remaining 50% will be released completely. Now this route of administration will not produce microbial resistance to antibiotic agent, will not cause any side effects and will sterilize the pocket. Locally administered antibiotics can also come in gel form.

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مطر Perio #2130/3/2015عالء The most commonly used antibiotics in periodontology are tetracycline and doxycycline. Tetracycline is no longer used in periodontology as it causes deciduous teeth staining, while doxycycline is still in use.

Doxycycline is given for a variety of periodontal diseases e.g. aggressive periodontitis, where two 100mg tablets a day are prescribed for the first 20 days then a one 100mg table a day for another 90 days.

Metronidazole is one of the best antibiotic drugs available that is given for anaerobic bacterial infections especially to treat necrotizing ulcerative gingivitis. As metronidazole is photosynthetic drug females who use the drug on permanent basis may complain of scars on the face after exposure to the sun.

Augmentin "Amoxicillin + Clavulanic acid" because some kinds of bacteria can produce beta lactamase enzyme that inactivate penicillin antibiotics, clavulanic acid was added to neutralize the anti-penicillin effect of bacteria. Clavulanic acid is added to the drug by different doses; 250 + 1.5 mg or 500 + 1.5 mg, that is why doubling the dose with augmentin doesn’t double the effect of the drug, while doubling the dose with the other types of antibiotics doubles the effect. The doses given to adults are: 375mg twice daily after meal or 625 mg twice daily or 1 gram twice a day.

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Many studies have suggested the principle of host modulation in the treatment of periodontal diseases. This principle relies on the fact that in order for any periodontal disease to develop two factors should be present: a pathogen i.e. bacteria and host response i.e. inflammatory mediators, destructive enzymes that are once released start to produce the clinical manifestations of the disease "bone loss, attachment loss, and swelling". For many years our treatment was concentrating more on removal of the cause "bacterial plaque" by different methods "scaling, brushing and antibiotic administration" but with host modulation principle we aim to modulate "neutralize" the host response to reduce the severity of inflammation and thus prevent the complications of the disease. In this case the body will not recognize the bacteria as a pathogen but instead it will be as any other foreign body present on the tooth.

The most commonly used host modulating drugs are NSAIDs and other types of medications but because of their side effects e.g. GI problems their use is still under study.

The End

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