Drug prescription in periodonticsI-Introduction: The practitioner in periodontics will resort to drug prescription for multiple reasons, the most important of which is the control of bacterial plaque by molecules with anti-infectious action (antiseptic or antibiotic) alongside other reasons which are the control of inflammation and pain II-drugs with anti-infectious action: A. Antibiotics1. Bacteria causing periodontal diseases Actinobacillus actinomycetemcomitans (Aa): facultative anaerobe, which although particularly involved in PJL can be found in adult or refractory periodontitis. The failures of mechanical treatments are explained by the very frequently described presence of this bacterium in the gingival tissues which justifies and indicates the prescription of a general antibiotic treatment. Porphyrhomonas gingivalis (Pg): very effective strict anaerobe with its endotoxins, elastases and collagenases, is very often found in the active sites of adult periodontitis and in PPR. Prevotella intermedia (Pi), Bacteroides forsythus (Bf), Eikenella corrodens (Ec), Campylobacter rectus (Cr), Fusobacterium nucleatum (Fn), are also present in the active sites of the disease. In periodontology, the main qualities sought for an antibiotic will be: · An activity on anaerobes · A low Minimum Inhibitory Concentration · A sufficient concentration in the gingival fluid and saliva · An absence of toxicity 2. the main antibiotics used in periodontology a. B lactams They inhibit the formation of the bacterial wall leading to cell lysis and therefore have a bactericidal mechanism. They have a broad spectrum and are effective against G- germs but encounter many resistances due to the production of blactamases. The addition of a blactamases inhibitor (clavulanic acid; AGMENTIN®) makes it possible to fight against the majority of periodontal-pathogenic bacteria. Penicillins have excellent tissue diffusion but are relatively low in concentration in the crevicular fluid compared to other molecules. They have a half-life of one hour on average and are active for at least 6 hours. They are eliminated by the kidneys, have many adverse effects (cutaneous, digestive) and rare allergic risks. Oral dosage: Amoxicillin 2g/day adult 50mg/kg/day child b. Cyclines These are antibiotics with bacteriostatic potential by inhibiting protein synthesis and opposing cell multiplication. They are active on Aa, Pg and Pi. have shown that in addition to antibacterial properties, cyclines have anticollagenase capacities and thus reduce the destruction of connective tissue. Other studies show that cyclines have an action on bone metabolism. In particular, minocycline and doxycycline seem capable of inhibiting bone resorption but also of stimulating osteoblastic activity in vitro and in vivo. From a pharmacokinetic point of view, it is important to note that cyclines have excellent diffusion in the crevicular fluid, which makes their use very interesting in periodontology. They have a long half-life (12-22 hours) and are eliminated by the kidneys. Dosage: 200mg/day for minocycline or doxycycline. c. Metronidazole Although its mechanism of action is poorly understood, it is considered bactericidal. It is particularly effective against Aa, Pi and Pg. It has a long half-life (10-12 hours) and excellent diffusion in tissue, saliva and gingival fluid. It can be used alone but is most often combined with spiramycin (BIOROGYL®) or penicillins. DOSAGE: 1 g/day in two doses for adults 30-40 mg/kg/day in 3 doses for children d. Spiramycin This is a macrolide that has a bacteriostatic action by inhibiting protein synthesis. It is effective against Pg, Pi, Capnocytophaga, Streptococcus, but inactive against Aa, Fn, Vr. Its interest lies in its good concentration in saliva and gingival fluid. There are few adverse effects and the classic drug interactions of macrolides have never been reported with spiramycin. For periodontal infections we will use it with metronidazole, this combination being synergistic on most periodontopathogenic bacteria. Dosage of the combination: 500-750mg metronidazole + 3 to 4.5 MIU spiramycin in two or three doses for adults and children over 15 years old. e. Clindamycin It is a lyncosamide effective against G+ cocci and bacilli and G- cocci but not very effective against Aa. It has a bactericidal mechanism of action by action at the level of the 50 S fraction of the ribosome. Its particular accumulation in neutrophilic leukocytes leads to high concentrations of the active ingredient in inflamed tissues. Clindamycin has the major side effect of pseudomembranous colitis, the incidence of which varies from 0.1% to 10%. 3- goal of antibiotic therapy: maximum suppression of pathogenic germs. patients in whom attachment loss progresses despite well-conducted conventional mechanical treatment, patients with PJL or other types of early-onset periodontitis patients whose general condition predisposes to the onset of periodontal disease. patients with severe, recurrent or acute periodontal disease (abscesses, GUNA, peri-implantitis) 4. Selection of antibiotic treatment according to the “second european workshop on periodontitis” – Cyclines are indicated for Aa-predominant infections – Metronidazole combined with amoxicillin ensures relatively predictable eradication of Aa and Pg – Metronidazole can stop the progression of refractory periodontitis when it is Pg and/or Pi infection. – Clindamycin has demonstrated efficacy in refractory periodontitis. It may be of interest in periodontal infections with a predominance of Peptostreptococcus, hemolytic streptococci, and other G- bacilli. But it must be prescribed with caution because of the high frequency of occurrence of pseudomembranous colitis. – Amoxicillin combined with clavulanic acid may constitute an alternative to clindamycin in the treatment of periodontitis. A precise knowledge of the etiology of a periodontal disease including the role of pathogenic germs and the susceptibility of the host is the key to therapeutic success. For cases where the therapeutic response is not satisfactory, a microbiological evaluation by culture of the germs present, followed by an antibiogram, is necessary in order to select the most appropriate molecule. Avoiding inappropriate administrations is still the best way to prevent resistance. 2. ANTISEPTICSare preparations that have the property of eliminating, killing microorganisms or inactivating viruses on living tissues (skin, mucous membrane, wound, etc.) without altering them. They are distinguished from disinfectants, which are products used to destroy local pathogens, instruments and all other materials. Antiseptics are most often used as mouthwashes and will therefore reduce the amount of bacteria present in the mouth. They will thus help us to unbalance the flora of the oral cavity. They are used during: The etiological phase of treatment The surgical phase The maintenance phase when there is a lack of plaque control and inflammation that recurs. The most commonly used antiseptic agents are: a. Chlorhexidine This is by far the most widely used anti-plaque agent and the one whose effectiveness seems to be widely demonstrated by the numerous studies carried out. This is Chlorhexidine digluconate first incorporated in mouthwashes at a concentration of 0.2%, this has been reported at 0.12% showing the same therapeutic properties. It is a broad spectrum antimicrobial agent, active on a large number of G+ and G- bacteria of supra and subgingival plaques as well as yeasts and parasites. The mechanism of action: a reduction in pellicle formation, an alteration of bacterial adsorption and/or adhesion to teeth alteration of the bacterial wall leading to lysis. Another interesting aspect of this product concerns its retention capacity on oral surfaces which concerns about 30% of the quantity of product introduced into the mouth. In this way the bacteriostatic efficacy can be maintained for several hours after its passage into the mouth. The activity of Chx can be reduced with contact with blood, pus as well as by certain anions. Similarly, it presents a clinical incompatibility with the excipients of a toothpaste: it precipitates in the presence of molecules such as stearate, lauryl sulfate and becomes inactive, so to optimize its effect, the mouthwash, if it is carried out after brushing, must be preceded by a vigorous rinse with water. administered in the form of mouthwash or subgingival irrigation in addition to the mechanical treatment of plaque removal. It will also be prescribed: When it is impossible to resort to mechanical elimination after surgery or to control bacteremia in patients at risk of endocarditis · For patients on cyclosporine after transplantation, those on chemotherapy and for disabled people. · Finally, when its antifungal action is sought, side effects appear after 10 to 15 days of treatment: blackish discoloration of the teeth, tongue and certain fillings; loss or change in taste b. Hexetidine It has an in vitro activity at best equal to that of Chx, but it does not have the same retention capacity on oral surfaces. Its anti-plaque effect is lower than that of Chx. c. Sanguinarine Extracted from the sap of sanguinaria canadensis and whose chemical name is benzophenathradine. It exists in the form of mouthwash and toothpaste. It has anti-plaque properties and a particularly interesting intra-oral retention. It is used as a mouthwash combined with zinc chloride. d. Quaternary ammoniums Cetylpyridinium hydrochloride is the main anti-plaque agent in this group. e. Metallic salts With zinc citrate (the most used), tin or copper. Metallic salts have anti-plaque potential and antimicrobial activity. At very high concentrations they can be bactericidal. Zinc citrate has moderate activity on the inhibition of plaque formation but acts on existing plaque. It has overall moderate activity compared to that of CHX. But associated with a non-ionic antimicrobial agent, triclosan, this anti-plaque system has good efficacy. f. Phenolic compounds Triclosan has broad-spectrum antimicrobial activity and anti-plaque properties but the side effects of its endocrine disrupting action have recently been raised which has led to a discussion on its administration. It is compatible with the formulation of mouthwashes and toothpastes and has good oral retention after brushing. Triclosan adsorbs the wall of salivary bacteria and adherent plaque and interferes with bacterial metabolism. · Listerine TM : This is a phenolic mouthwash based on essential oils of menthol, thymol, eucalyptus and methylsalicylate. It is said to be able to extract lipopolysaccharides derived from endotoxins of Gram-negative bacteria contained in dental plaque, which would give it anti-plaque activity. g. Hydrogen peroxide Hydrogen peroxide can be used as a mouthwash, in local application mixed with sodium bicarbonate which potentiates its action or in subgingival irrigation. However, irrigation with 1% hydrogen peroxide is less effective than 0.12% Chx in reducing the amount of plaque and gingival inflammation. II-Medicines with anti-inflammatory action and painkillers: Are most often prescribed in periodontology in the following cases In emergencies (periodontal abscess, GUNA) To prevent the painful after-effects of surgical procedures In the case of occlusal trauma and SADAM Most authors have shown a close correlation between the level of prostaglandins and periodontal disease. The increase in PGE2 is indicative of a loss of gingival attachment. NSAIDs act on the acute phase of inflammation by mainly inhibiting the synthesis of prostaglandins. Due to the significant side effects of NSAIDs, it would seem more interesting to use local forms that are also effective. The disadvantage of these drugs is their symptomatic action on the signs of inflammation, which can mask the infection and promote its spread. The administration of NSAIDs may be justified after suppression of the main etiology, bacterial plaque, during prolonged treatment and in association with antibiotic therapy. For analgesics; paracetamol remains the molecule of choice. It may possibly be associated with dextropropoxyfen or codeine. CONCLUSION: the well thought-out prescription of antibiotics and antiseptics in periodontics allows to lead to the potentiation of the mechanical action of the elimination of bacterial plaque provided that this action is well accomplished, failing which the chemical action of the drugs will be limited or even ineffective. Anti-inflammatories and analgesics provide desirable comfort during the treatment and during the healing process of the treated periodontium. |
Drug prescription in periodontics
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