Drug prescription in periodontics

Drug prescription in periodontics

Introduction

Periodontal diseases are multifactorial inflammatory pathologies generally of infectious origin manifested by an attack on the supporting tissues of the tooth. These diseases result from the breakdown of homeostasis between the oral bacterial flora and the host’s defenses. The bacterial etiology in periodontal disease is demonstrated and strongly supported by clinical studies, which is why the use of antimicrobial therapeutic means, whether mechanical or chemical, is essential to prevent and treat gingivitis and periodontitis. The prescription of antimicrobial agents has always been current in periodontics because the main target in the treatment of periodontal diseases has always been and until now dental plaque.

1. Antibiotics
2. Justification for the use of antibiotics in periodontics

• Periodontal diseases are infectious diseases
• Some advanced forms (aggressive periodontitis) are characterized by a cause associated with a local or general alteration of the immune system
• The progression and recurrence of certain diseases after conventional (implemented) treatment cannot be applied due to the persistence of certain pathogens

2. Qualities sought in an antibiotic

In periodontology, the main qualities sought for an antibiotic will be: 

• An activity on anaerobes
•  A suitable minimum inhibition concentration (MIC)
•  Sufficient concentration in gingival fluid and saliva 
• An absence of toxicity.

3. Indications for antibiotic therapy

• Aggressive periodontitis
• Recurrence during supportive therapy
• Poor or average clinical response after conventional treatment (especially for deep pockets and LIR)
• Possibility of superinfection from other infected oropharyngeal sites
• In emergency:
  • Periodontal abscess with deterioration of general condition
  • Suppuration
  • GUN, PUN
• Antibiotic prophylaxis in patients at risk of infection

4. Properties and methods of administration of the main antibiotics in periodontics

1-general antibiotic therapy

1-1-B-lactams:

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 in adults.

50mg/kg/day in children.

1-2-spiramycin: 

 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 in 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. 

Oral dosage: Spiramycin 6MUI/day

1-3-cyclines: 

These are antibiotics with bacteriostatic potential by inhibiting protein synthesis and opposing cell multiplication. They are active on Aa, Pg and Pi. (Golubet coll1983) showed that in addition to antibacterial properties, cyclins had anticollagenase capacities and thus reduced the destruction of connective tissue. Other studies show that cyclins have an action on bone metabolism. In particular, minocycline and doxycycline seem capable of inhibiting bone resorption (Gomes, Kapisz-Wolikowet Jaffar ) but also of stimulating osteoblastic activity in vitro (Rompenet coll1995) and in vivo (Druryet Yukma1991).

-They would also be able to stimulate the adhesion and spreading capacities of periodontal, gingival and dermal osteoblasts and fibroblasts (Somermanet coll 1988).

-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 renal route.

Dosage: 200mg/day for minocycline or doxycycline

1-4-metronidazole:

-Although its mechanism of action is poorly understood, it is considered bactericidal. It is particularly effective, through its active metabolites, against Aa, Pi and Pg. 

-It has a long half-life (10-12h) and excellent diffusion in salivary tissue and gingival fluid. 

-It can be used alone but is most often combined with spiramycin or penicillins.

DOSAGE: 750 to 1 g/day in two doses in adults

30-40mg/kg/day in 3 doses in children

1-5-associations:

• Augmentin: clavulanic acid + amoxicillin
• Rodogyl: spiramycin+metronidazole
• Amoxicillin + metronidazole.

Drug prescription in periodontics

2 – Local antibiotic therapy

Topically administered antibiotics, at much higher concentrations than can be achieved by systemic antibiotic therapy, help eliminate residual bacteria at a specific site.

 Doxycycline (Atridox®), minocycline (Parocline®), and metronidazole (Elyzol®) have been marketed as gels. 

These systems appear suitable for the treatment of recurrent and/or refractory periodontitis, the treatment of individual sites refractory to conventional therapy, and the treatment of patients with periodontitis associated with systemic diseases (diabetes, etc.).

3-Antibiotic prophylaxis

The principle is to cover a non-surgical but bloody act in patients at risk of infection.

3-1-Group A

Local or general infectious risk in patients susceptible to infection due to an underlying pathology or drug treatment 

• Glomerulonephritis or kidney disease
• Uncontrolled diabetes
• Malignant pathology 
• Infectious disease (AIDS, hepatitis)
• Immunocompromised subjects
• Subjects who have undergone radiotherapy in the cervicofacial area (osteoradionecrosis)
• Antibiotic prophylaxis 2 days before the procedure and continued afterwards

3-2- group B 

• Risk of infection linked to a secondary location of the bacteria, creating an infectious focus at a distance from the primary focus 
• These are heart diseases at risk of infective endocarditis and subjects with a valve prosthesis.
• Antibiotic prophylaxis 1 hour before the procedure:
  • Amoxicillin; 2g in adults and 50mg/kg in children
  • Clindamycin; 600 mg in adults, 15 mg/kg in children
  • Pristinamycin: 1g in adults, 25mg/kg in children

Drug prescription in periodontics

2. Anti-inflammatories

2.1. Steroids (glucocorticoids)

• Properties

• Anti-inflammatory action at low doses, 
• No analgesic effect in the absence of inflammation  
• Anti-allergic action     
• High-dose immunosuppressants
• Dosage

Prednisolone; 3 tablets in the morning in a single dose for adults and 1 mg/kg for children 

Oropivalone; 1 to 4 tablets to suck

• IND

After surgery

Lockjaw (DAM)

2.2. Non-steroidal NSAIDs

• The properties

• Painkiller
• Antipyretic
• Anti-inflammatory
• Antiplatelet agent
• Classification

• For rheumatological use: indole derivatives, pyrazoles, oxicam
• For dental use:
  •  Arylcarboximates: diclofenac, flubiprofen, ibuprofen, ketoprofen
  • Fenamates: nifluric acid (nifluril), nefenamic acid (ponstyl)
  • Indole derivatives: indomethacin (indomet)
• IND

For analgesic purposes post-surgery

3. Painkillers

3.1. Definition

Analgesics are symptomatic drugs that act non-specifically on painful sensations, which they alleviate or eliminate without acting on their cause.

Drug prescription in periodontics

3.2. Classification

Level 1	Level 2	Level 3
Non-morphine analgesics	Weak opioid analgesics	Strong opioid analgesics
ParacetamolAspirinNSAIDs	CodeineDestroproxyphenetramadol	MorphineFentanylHydromorphoneoxycodone
Mild to moderate pain	Moderate to severe pain	Severe to very severe pain

3.3. Indications 

• Necrotizing periodontal disease
• Periodontal abscess
• Herpetic gingivostomatitis
• Pericoronitis
• The DAM
• Septum syndrome
• Post surgery

4. Antiseptics

4.1. Definition

These are chemical substances with an antimicrobial effect, their action is rapid but transient and also non-specific on microorganisms, intended for external use (skin, mucous membranes and wounds).

4.2. The most commonly used antiseptics

• Chlorhexidine
• Hexitidine
• Sanguinarine
• Quaternary ammoniums
• Phenolic compounds
• Hydrogen peroxide

4.3. Indications 

• In addition to mechanical treatment during etiological treatment, after surgical treatment or during supportive therapy
• When it is impossible to brush after surgery
• Controlling bacteremia in patients at risk of infection
• Disabled people 

1-Chlorhexidine (BB or irrigation)

• The most widely used antiplaque agent
• Broad spectrum bactericide
• Adhesion capacity to oral surfaces 
• Mechanism of action:

• Reduction of acquired film formation
• Impaired bacterial adsorption and/or adhesion to teeth
• An alteration of the bacterial wall leading to lysis 

• Its activity may be reduced in contact with blood, pus,
• Clinical incompatibility with some toothpaste excipients (stearate, lauryl sulfate) and becomes inactive
• Side effects: blackish discoloration of teeth, tongue, fillings, loss or change in taste

2-hexitidine

• Its action is at best equal to Chlorhexidine
• It does not have retention capacity on oral surfaces
• Antiplaque action lower than Chlorhexidine

3- Sanguinarine

• In the form of BB or toothpaste
• To be effective, you must use toothpaste and BB cream simultaneously 4*/day

4-phenolic compounds

• Triclosan:
  • Broad spectrum antimicrobial activity
  • BB or toothpaste
  • Good oral retention
• Listerine  :

It 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 (Fine et al. 1985) which would give it an anti-plaque activity.

Conclusion

Although the role of mechanical intervention in the prevention and treatment of periodontal disease has been clearly identified, it is not always sufficient to control the progression of the disease. The choice of an appropriate chemotherapeutic agent within the framework of an adapted therapeutic protocol , in conjunction with mechanical intervention, optimizes the possibility of controlling the disease. At present, there is no single therapeutic approach that provides a beneficial response for all patients. Clinical trials are still needed to objectively evaluate the most effective complementary medication in the prevention and treatment of periodontal diseases.

Drug prescription in periodontics

  Wisdom teeth can cause infections if not removed.
Dental crowns restore the function and appearance of damaged teeth.
Swollen gums are often a sign of periodontal disease.
Orthodontic treatments can be performed at any age.
Composite fillings are discreet and durable.
Composite fillings are discreet and durable.
Interdental brushes effectively clean tight spaces.
Visiting the dentist every six months prevents dental problems.
 

Drug prescription in periodontics