Prescribing for Periodontal Disease Becky Coulter

Periodontal Disease Defined: ‘Any condition affecting the tissue of periodontium.’ Common presentation: Chronic periodontitis (affects 54% UK adults.) Pathogenesis: ‘Complex disease’ Abnormal host response (80%) to presence of plaque biofilm results in tissue damage. Risk Factors: ( Smoking, diabetes, poor diet, stress poor OH) Management: 1. Modify risk factors 2. Disruption / removal biofilm. 3. Antimicrobials ...

Antimicrobial Resistance Antibiotics prescribed responsibly and used appropriately. ‘Socransky 1998’ Different bacteria associated with different periodontal states. ‘Red Complex’ = active periodontitis. Bacteria included – Pg Porphyromonas Gingivalis Td Treponema denticola Tf Tanerella Forsythia Aggressive periodontitis = Aa AggregatibacterActinomycetemomitans Diagnosis essential appropriate antimicrobial management.

Periodontal Diagnosis

Periodontal diagnoses appropriate for adjunct Antimicrobials Microbial tissue invasion= antimicrobials as an adjunct to LOCAL MANAGEMENT ANUG Necrotising ulcerative disease. Presents poor OH & Smokers. Associated stress & compromised immune response. Aggressive Periodontitis Genetic susceptibility. Marked attachment loss and minimal plaque deposits. Periodontal Abscess Systemic involvement- SIRS, Cellulitis, Pyrexia. Life threatening!

Host Consideration Host inflammatory response = role periodontal disease progression. Aim: Protective response – immunoregulatory process - response to microbial challenge 8% population response is unregulated = damage. Gene regulated response = genetic conditions susceptibility to periodontal disease. Conditions: Papillon Lefevre syndrome Chediak- Higashi syndrome Exaggerated inflammatory response is systemic affecting general health. Associated conditions : type 2 diabetes atherogenic cardiovascular disease stroke

Antimicrobial Efficacy Dependant on microbial sensitivity to selected drug. Aim: To achieve MIC ( minimum inhibitory concentration) in Blood & Gingival crevicular fluid. Role of prescriber: Appropriate dose & regime to minimise bacterial resistance.

Periodontal Abscess Manage: Local: Achieve drainage – removal source of infection -RSD via periodontal pocket - XLA External incision Antimicrobial indicated: Systemic (raised temperature, lymphadentopathy, pyrexic) SIRS criteria  Hospital Prescription: Amoxicillin Capsules 500mg. Send: 15 Capsules. Label: Take 1 capsule three times daily for five days. Side effects & warnings: Hypersensitivity/ anaphylaxis

ANUG Manage Local: Oral hygiene advice Scaling/ debridement under l.a. Smoking cessation advice Dietary advice Antimircrobial: Severe infection Systemic involvement Prescription: Metronidazole Tablets 400mg, tid, up to 5days * rv after 2-3days and discontinue if resolved. Side effects & warnings: Avoid alcohol Interaction with warfarin Contraindicated: Alcoholics, pregnancy, warfainised patients. (Amoxicillin alternative) Follow up: Assess OH Resolution of infection Additional scaling & cleaning

Aggressive Perio Diagnosis: consider specialist referral Manage Local: Debridement completed 7-14days Antimicrobial: Indicated all diagnosis of aggressive perio Immediately post debridgement Prescription: Amoxicillin Capsules 500mg Send: 15 capsules Label: take 1 capsule three times daily for five days Metronidazole Tablets 200mg Send: 15 tablets Label: take 1 tablet three times daily for five days Side effects & warnings: As before Follow up: Referral to specialist *Aggressive perio: systemic adjunct antimicrobals (+) greater reduction in probing depth & clinical attachment level gain over RSD alone. (-) only short term effect.

Local delivery – chronic periodontitis? Local delivery of antimicrobials Indicated as adjunct - optimal plaque control - debrided root surfaces - isolated sites of remaining active disease -surgical cleaning not feasible ‘Periochip’ Active drug: Chlorhexidine Delivery: inserted to perio pocket post debridement Dose: 125mcg/ml CHX released over 7days ‘Atridox’ Active drug: Doxycycline Delivery: periodontal pocket Dose: 8.5% initial 24hours ( 7-10days). Risks & side effects: Concerns over maintaining optimal drug concentration = effective. MIC. Local administration antimicrobials role antibiotic resistance. Cost effectiveness. General poor evidence and not routinely used!!

Dentine Hypersensitivity Definition: Dental pain from exposed dentine surfaces in response to stimuli. Symptoms: Pain, difficult diagnosis & management. Management: OTC desensitising products Action: Disrupt nerve transmission. Occlude exposed tubules. Prescription: Sodium Fluoride Toothpaste, 1.1% (5000ppm) Send: 51g Label: Brush teeth for 3mins, after meals using 2cm, before spitting out, three times daily.

Erosive/ Ulcerative Conditions Conditions: Apthous ulceration, Erosive LP, Vesiculobulous conditions Symptoms: Pain Prescriptions: Topical ‘Difflam’ Benzyldamine Mouthwash Send: 300ml Label: Rinse or gargle using 15ml every 11/2 hours as required Systemic Betamethasone Soluble Tablets 500mcg Send: 100tablets Label: 1 tablet dissolved in 10ml water as mouthwash four times daily.

Summary Host immune response key in periodontal disease process. 2. Management – effective OH - managing risk factors -behavioural change -root surface debridement 3. Antimicrobial prescribing = ADJUNCT to biofilm control

Thank you References PRESCRIBING FOR PERIODONTAL DISEASE FIONA M BLAIR, IAIN LC CHAPPLE. PRIM DENTAL JOURNAL. 2014.3(4) 38-43. FGDP (UK) ‘Antimicrobial prescribing for general dental practitioners.’ 2014 * Access FGDP website. Login: ‘openstandards.’ 3. SDCEP ‘Drug Prescribing in Dentistry.’ 3rd Edition. January 2016.