1. Prescribing for Periodontal Disease
Becky Coulter

2. 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 ...

3. 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.

4. Periodontal Diagnosis

5. 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!

6. 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

7. 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.

8. 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

9. 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

10. 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.

11. 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!!

12. 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.

13. 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.

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

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