current use Abx

Question 1

Philosophy of Treatment via antimicrobials

Answer 1

Periodontitis:
* Is caused by bacteria
* A chronic disease
* Recurs or re-infects

Arrest the disease:
Alter the microflora to prevent reinfection
Maintain the disease in an arrested state

Question 2

Effective Antimicrobial qualities

Answer 2

Question 3

Comparative Dosage: Crevicular levels Versus Blood levels
* Cumulative oral dosage can have the problem
of? examples?
* Small dose of local delivery antimicrobial leads
to what crevicular levels?
* An example of a 250 mg tablet of Tetracycline
* Delivered systemically:
* Delivered locally:

Answer 3

• Cumulative oral dosage can have the problem
  of side effects: Gastrointestinal problems or tolerance
• Small dose of local delivery antimicrobial leads
  to high concentration at crevicular level
• An example of a 250 mg tablet of Tetracycline
• Delivered systemically: 2ug in peripheral blood level;
  16ug in GCF
• Delivered locally: 1600 ug in GCF

Question 4

An antibiotic strength ?? times greater than
the systemic therapeutic dose may be required
to be effective against the bacteria residing in
plaque biofilms.

Answer 4

An antibiotic strength 500 times greater than
the systemic therapeutic dose may be required
to be effective against the bacteria residing in
plaque biofilms.

Question 5

never use Abx in the absence of? why?

Answer 5

Never use antimicrobial agents in the absence of
mechanical debridement

Disrupt the biofilm physically to allow antibiotic
agents gain access to the periodontal
pathogens and inhibit biofilm formation

Question 6

Chorhexidine
* %?
* toxicity/hyper sensitivity?
* Active against most?
* microbial resistance?
* Cannot reach?
* Sides effects?

Answer 6

• Chlorhexidine gluconate (CHX)(0.12-0.2%): the most studied and effective rinsing agent for plaque
  inhibition and prevention of gingivitis
• No systemic toxicity, rare hypersensitivity
• Active against most bacteria and fungi
• No microbial resistance reported
• Cannot reach the site subgingivally
• Sides effects: Taste alteration, tooth discoloration, increased supragingival calculus formation

Question 7

stains of CHX

Answer 7

• Extrinsic brown discoloration on the teeth from an individual rinsing twice a day for 3 weeks with 0.2% chlorhexidine mouth rinse (Europe). Can be alleviated with 0.12% formulation (US).
• Beverages like tea, coffee and red wine will aggravate this superficial staining.** Can be removed **using prophy paste

Question 8

CHX mechainsm
charge?
lower concetrations?
higher concentrations?

Answer 8

Chlorhexidine is a positively-charged molecule that binds to the negatively-charged sites on the cell wall; it destabilizes the cell wall and interferes with osmosis.
* Lower concentrations leads to increased permeability and leakage.
* Higher concentrations leads to precipitation of cytoplasmic contents inducing microbial cell death

Question 9

substanstivity of CHX

Answer 9

• High substantivity
• Adhere to soft and hard tissues and then be released
  over time
• Slow release over 12 hours

Question 10

Application of CHX
* As adjunct to regular oral hygiene methods during?
* challenged pts?
* Jaw?
* post surgery?

Answer 10

• As adjunct to regular oral hygiene methods during Phase I therapy (SRP) in high risk individuals (systemically compromised, refractory cases, etc)
• Mentally or physically challenged patients with low manual dexterity
• Jaw fixation, BRONJ
• 1st - 2nd week post surgery

Question 11

Essential Oils
* Mouth rinse with?
* Antiplaque/ gingivitis index
* Side effects:

Answer 11

• Mouth rinse with eucalyptol, menthol, methyl salicylate, thymol
• Antiplaque effects and significant reduction in gingivitis index
• Side effects: Burning sensation and tooth staining

Question 12

Side Effects essential oil rinses:
* Most anti-plaque rinses contains?
* Carcinogenic?
* Not recommended in?

Answer 12

• Most anti-plaque rinses contains alcohol as a vehicle to deliver antiseptic ingredients.
• Critical assessment of the literature does NOT support an association of alcohol‐containing mouth rinses and cancer.
• Not recommended in recovering alcoholics (craving for alcohol), in patients taking metronidazole or disulfiram (drug interaction).

Question 13

essential oil rinse mechanisms?
* Cell wall?
* Inhibition of?
* Extraction of?
* Antiinflammatory action based on?

Answer 13

• Multiple mechanisms proposed
• Cell wall disruption
• Inhibition of bacterial enzymes
• Extraction of endotoxins derived from lipopolysaccharide (LPS) of Gram-negative bacteria
• Antiinflammatory action based on antioxidant activity

Question 14

Hydrogen Peroxide
* Beneficial effects were seen with H2O2 levels above?
* Prolonged use of H2O2 decreased?
* Conflicting results was shown on the effectiveness of?
* Therapeutic delivery of H2O2 to prevent periodontal disease required?

Answer 14

• Beneficial effects were seen with H2O2 levels above 1%.
• Prolonged use of H2O2 decreased plaque and gingivitis indices.
• Conflicting results was shown on the effectiveness of 1.5% H2O 2 rinse.
• Therapeutic delivery of H2O2 to prevent periodontal disease required mechanical access to subgingival pockets. **Never use antimicrobial agents in the absence of mechanical debridement
  **

Question 15

Side Effects H2O2
* 3% H2O2 or less used daily showed?
* carcinogenic?
* ADA and FDA have concerns regarding?
* Possible?

Answer 15

• 3% H2O2 or less used daily showed occasional irritant effects: In small number of subjects with preexisting ulceration and When combined with high levels of salt solutions.
• In animal model, 30% H 2O2 was referred to as a co-carcinogen; 3% or less, no co-carcinogenic activity/adverse effects were observed.
• ADA and FDA have concerns regarding long-term use
• Possible co-carcinogen and impaired wound healing

Question 16

Subgingival Irrigation
* when used as a monotherapy?
* Tissue invasive organisms?

Answer 16

• Significantly reduced monitored bacteria when
  used as mono therapy, but not eliminated: Microbiota rebound to baseline within 1 to 8 weeks after short-term subgingival irrigation
• Tissue invasive organisms doesn’t respond well.
• After 6 months of irrigation every 2 weeks with 3% hydrogen peroxide, limited success was achieved in reducing high concentrations of Actinobacillus actinomycetemcomitans

Question 17

Properties of sub g irrigation
* Reaches the site with?
* Achieved ?% penetration in pockets of less than 6mm when tip was place ?mm apical to the margin.
* ?% penetration in deeper pockets when canula was placed ?mm apical to the margin.

Answer 17

Properties
* Reaches the site with a sufficient concentration
* Achieved 90% penetration in pockets of less than 6mm when
tip was place 1mm apical to the margin.
* 70-80% penetration in deeper pockets when canula was placed
3mm apical to the margin.

Question 18

substantivity of sub g irrigation:
* Blood and proteins?
* retained to have an effect?
* 50% of a fluorescein labeled hydroxypropylcellulose gel injectedsubgingivally was washed out of pockets within?
* The gingival crevicular fluid is replaced in a 5 mm pocket how many times per hour?
* The half life of an antimicrobial irrigation concentration is ?

Answer 18

• Lack of substantivity
• Blood and protein can deactivate the drug
• The medicament may not be retained long enough to have an efficacious effect.
• 50% of a fluorescein labeled hydroxypropylcellulose gel injectedsubgingivally was washed out of pockets within 12.5 minutes
• The gingival crevicular fluid is replaced in a 5 mm pocket 40 times over an hour period
• The half life of an antimicrobial irrigation concentration is 1 minute.

Question 19

subg CHX irrigation

Answer 19

• Single use to reduce the bacterial load; adjunctive use to gain the antiseptic effect
• A syringe and a jet irrigator with a cannula were equally effective.
• Low irrigation forces were effective

Question 20

Betadine® subg irrigation
contents?
* Can be used how?
* Do not use when there is history of?
* Use with caution in ?

Answer 20

Betadine® (10% povidone-iodine and 1% free iodine)
* Can be used diluted as an irrigant
* Do not use when there is history of iodine sensitivity
* Use with caution in pregnancy and lactation to prevent inducing transient hypothyroidism in newborn

Question 21

Local Antimicrobial Delivery

Answer 21

• LAD is the medicament placed in a periodontal pocket with a delivery system and released in a controlled manner, allowing minimum inhibitory concentration for 7 days.

Question 22

LAD forms

Answer 22

1. Chip/Slab/Strip/Film
2. Injectable gel
3. Fiber
4. Microsphere

Question 23

Ideal Properties LAD
* Effective against?
* Low risk of?
* systemic absorption?
* Biodegradable?
* Easy?
* Enhances?

Answer 23

• Effective against periodontal pathogens: Kill the pathogens effectively and Reach the site really well
• Low risk of bacterial resistance
• Low systemic absorption: Good concentration and substantivity
• Biodegradable
• Easy to use
• Enhances scaling and root planing

Question 24

Indications for LAD
* When local sites with inflammation have not
responded to? example situations?
Always use as?

Answer 24

• When local sites with inflammation have not
  responded to periodontal or maintenance therapy.
  Examples:
• Residual isolated pockets ≥5mm, not responding favorably to initial SRP with BOP at re-evaluation.
• Residual pockets after periodontal surgery.
• Recurrent isolated pockets ≥5mm with BOP at maintenance.
  Always as adjunct therapy, never use alone.

Question 25

PerioChip * Perio-Chip®: bioresorbable polymer with what agent? * Inserted in the pocket ?mm * Release takes? * Dissolves within? * Significant improvement? when used with?

Answer 25

* Perio-Chip®: bioresorbable polymer with 2.5 mg Chlorhexidine (film) * Inserted in the pocket ≥ 5mm * Release takes 7days * Dissolves within 7-10 days, does not require removal. * Significant improvement in CAL when used with SRP

Question 26

Atridox active Abx? * Delivered how? * Controlled release over? * Significant improvement in? used with? * Do not use in patient with?

Answer 26

Atridox®: 10 % doxycycline hyclate gel * Delivered subgingivally by canula to flow to the base of the pocket and adapt to root morphology * Controlled release over 21 days * Significant improvement in CAL when used with SRP * Do not use in patient with hypersensitivity to doxycycline or drugs in the tetracycline class.

Question 27

arestin * Abx? * Bacteriostatic by? * spectrym? * Significantly reduced what in smokers?

Answer 27

* Arestin® : 1mg minocycline HCl in bioabsorbable microspheres * Bacteriostatic by inhibiting protein synthesis * Broad spectrum * Significantly reduced red complex bacteria in smokers greater improvement in PD, CAL regardless of smoking status

Question 28

actisite * Abx/form * Currently? * Slow release over? * application? * Improve ? when combined use with SRP in ? months but no difference after?

Answer 28

* Actisite®: Non-resorbable, monolithic fiber contains 25% tetracycline-HCL powder * Currently unavailable * Slow release over 10 days * Packed into the pocket and left in place for 7-12 days, need removal. * Improve PD, BOP, CAL when combined use with SRP in 6 months but no difference after 5 years

Question 29

LAD in Peri-implant Diseases

Answer 29

* Local Drug Delivery is not effective with implants * May partially detoxify the implants but no long-lasting effects * May be used as a step in implant recovery for regeneration of bone around implants in conjunction with grafting and GTR but there is still no evidence in literature

Question 30

Laser Therapy stands for? * basic strucutures? * color/ wavelength? * The wavelength and other properties are determined primarily by?

Answer 30

“Light Amplification by the Stimulated Emission of Radiation” * 3 basic structures: 1. An energy source, 1. An active lasing medium 1. Two or more mirrors that form an optical cavity or resonator * Monochromatic light with a single wavelength: The wavelength and other properties are determined primarily by the composition of an active medium

Question 31

laser interactions with tissue

Answer 31

msot important is absorption

Question 32

* Absorbing chromophores of laser therapy

Answer 32

* Intraoral soft tissue: Melanin, Hemoglobin, and Water * Dental hard tissues: Water and Hydroxyapatite

Question 33

Absorption * 60°C< temperatures <100°C, proteins/ underlying tissues? * When reaching 100°C, what occurs? * At temperatures > 200°C, the tissue is? * Light energy is converted into?

Answer 33

* 60°C< temperatures <100°C, proteins begin to denature without vaporization of the underlying tissue. * When reaching 100°C, vaporization of the water within the tissue occurs (ablation) * At temperatures > 200°C, the tissue is dehydrated and then burned, resulting in carbonization (undesirable effect). * Light energy is converted into heat and photochemical effects occur depending on the water content of the tissues.

Question 34

Absorption * Different laser wavelengths have different? result of this?

Answer 34

* Different laser wavelengths have different absorption coefficients with respect to these primary tissue components, making the laser selection procedure-dependent

Question 35

Diode Lasers * Used in? * Not effective for? * Low-level laser has been recommended for?

Answer 35

* Used in soft tissue treatments * Not effective for calculus removal despite it’s bactericidal efficacy * Low-level laser has been recommended for pain reduction and enhancing wound healing due to its anti-inflammatory effects

Question 36

Nd:YAG laser * Highly absorbed by? * Effective in? * Used for ?

Answer 36

* Highly absorbed by the pigmented tissue * Effective in cutting and coagulating dental soft tissues * Used for nonsurgical sulcular debridement in periodontal disease control (Laser Assisted New Attachment Procedure (LANAP))

Question 37

Erbium laser * Laser of choice for treatment of? * High affinity for? * Highest absorption of what for any laser? * Can be used for?

Answer 37

* Laser of choice for treatment of dental hard tissues * High affinity for hydroxyapatite * Highest absorption of water in any dental laser wavelengths * Can be used for soft tissue ablation (water vaporation)

Question 38

ideal properties of systemic Abx

Answer 38

* Effective against ALL periodontal pathogens * Substantive and non-toxic * Not in general use for other diseases **No single antibiotic at concentrations achieved in GCF satisfies the above requirements **

Question 39

Adjunct Antibiotics In phase I therapy

Answer 39

* Tetracyclines: Tetracycline, Doxycycline * Penicillins: Amoxicillin, Augmentin * Azithromicin * Metronidazole

Question 40

Tetracyclines * High concentration in? * spectrum bacteriostatic? * Antimicrobial effect: highly effective against? but? * tissue destruction? * Photosensitivity? * Doxycycline (DCN) compliance?

Answer 40

* High concentration in GCF (2-10 fold than serum) * Broad spectrum bacteriostatic * Antimicrobial effect: highly effective against A . actinomycetemcomitans, but resistant strains are now common * Anti-collagenolytic effects: inhibit connective tissue destruction and promote repair * Photosensitivity: severe skin burns * Doxycycline (DCN): Better compliance because it can be given qd or bid

Question 41

Penicillins * A group of? * spectrum? * Affected by?: can be protected by? * Augmentin? * Up to ?% of humans are allergic to penicillins, Substitute? * Can be used in combination with?

Answer 41

* A group of β-lactam antibiotics * Characteristics * Broad spectrum bactericidal * Affected by beta-lactamases: can be protected by clavulanic acid * Amoxicillin+clavulanic acid=Augmentin * Up to 10% of humans are allergic to penicillins * Substitute with ciprofloxacin, azithromycin or clindamycin * Can be used in combination with metronidazole

Question 42

Azithromycin * Bacteriostatic for? * Effective against most? * tissue concentration? * Better compliance because ? * Can be used in combination with?

Answer 42

* Bacteriostatic for most pathogens * Effective against most anaerobes, gram-positive and negative bacteria. * Good tissue concentration * Better compliance because it is given qd * Can be used in combination with metronidazole

Question 43

Metronidazole * Attain effective antibacterial concentration in? * Particularly effective against? * Adverse reaction when taken with? * Do not combine it with?

Answer 43

* Attain effective antibacterial concentration in gingival tissue and GCF * Particularly effective against anaerobic bacteria and spirochetes * Bactericidal * Adverse reaction (nausea, vomiting, cramping) when taken with alcohol. * Do not combine it with warfarin, lithium, phenytoin, cyclosporin

Question 44

Antibiotic Regiment In phase I therapy which abx? dosages? time frame?

Answer 44

Metronidazole + Amoxicillin combination * van Winkelhoff cocktail: 375mg Amox+250mg Metro. TID 7 days * 500 mg of Amox. and 500 mg of Metro. TID * 250 mg of Amoxicillin and 250 mg of Metronidazole TID or QID * 7 days or 14 days of administration

Question 45

Antibiotic Regiment In acute periodontal abscess cases

Answer 45

Question 46

Host Modulation

Answer 46

* Aims to reduce tissue destruction by modifying the host response

Question 47

Host Modulation goals * Reduce excessive amounts or activity of? * Increase? * Modulate activty of what cells? * No impact on? * Promote ?

Answer 47

* Reduce excessive amounts or activity of lytic enzymes/cytokines/inflammatory mediators * Increase anti-inflammatory mediator amounts or activity * Modulate osteoblast and osteoclast activity * No impact on physiologic cell function; contribute to sustained control of “harmful” bugs * Promote connective tissue repair or regeneration and produce clinically significant results

Question 48

NSAIDS * Target? * Selective? * Indomethacin, flurbiprofen and naproxen long term daily use (up to 3 years) can lead to? * Serious side effects ? used as adjunct?

Answer 48

* Target prostaglandins and inflammation * Selective COX-1 vs COX-2 inhibitors * Indomethacin, flurbiprofen and naproxen long term daily use (up to 3 years) can lead to slower disease progression * Serious side effects such as GI irritation, liver and renal damage/ dysfunction Not used as adjuncts in periodontal therapy

Question 49

Bisphosphonates * Disrupt? * Can improve? * Serious side effects with? approved application in periodontal therapy?

Answer 49

* Disrupt osteoclast activity * Can improve alveolar bone density but the role in disease progression in humans is unclear * Serious side effects with IV agents (osteonecrosis of the jaw after oral surgery No approved application in periodontal therapy

Question 50

Tetracyclines and conn tissue

Answer 50

* Tetracyclines (TCs) inhibit connective tissue breakdown

Question 51

TCs inhibition of conn tissue breakdown

Answer 51

* Mediated by extracellular mechanisms * * Direct inhibition of active MMPs * * Inhibition of oxidative activation of Pro-MMPs * * Inhibition of MMPs indirectly decreases serine proteinase activity * Mediated by cellular regulation * * TCs decreases cytokines, iNOS, PLA, prostaglandin synthase * * Effects on protein kinases (MAPA)** * Mediated by pro-anabolic effects * * TCs increases collagen production * * TCs increases osteoblast activity and bone formation

Question 52

Subantimicrobial Dose Doxycycline (SDD

Answer 52

* Among tetracyclines, Doxycycline has the best anticollagenolytic activity and better GI absorption * Currently the only FDA approved host modifier as adjunct to SRP

Question 53

SDD administration * ? mg doxycycline, time frame? * Adjunct to? * SDD doesn’t result in? * Contraindicated in? * May reduce efficacy of?

Answer 53

* 20 mg doxycycline twice daily or 40mg once daily, for 6-9 months * Adjunct to thorough and high-standard SRP * SDD doesn’t result in antibacterial effects/development of resistant strains/multiantibiotic resistance * Contraindicated in pregnancy or children for the risk of permanent teeth discoloration * May reduce efficacy of contraceptives

Question 54

SDD * name/mech? * FDA approved? * DO NOT USE AS? * Clinical significance?

Answer 54

* Periostat (CollaGenex Pharmaceuticals) is a host-modulating agent. It inhibits host collagen- degrading enzymes * FDA approved host modifier as adjunct to SRP * DO NOT USE AS STAND-ALONE THERAPY * Clinical significance? = 0.2-0.4mm difference in attachment gai

Question 55

Antibiotic Prophylaxis

Answer 55

Heart conditions and Prosthetic joints if MD says so Apply only to dental procedures requiring manipulation of the gingival tissue or the periapical region of teeth, or perforation of the oral mucosa.

Question 56

heart conditons for Abx prophylaxis

Answer 56

Only patients at the highest risk of infective endocarditis

Question 57

porsthetic joints and Abx prophylaxis

Answer 57

* For patients with a history of complications associated with their joint replacement who are undergoing dental procedures including gingival manipulation or mucosal incision, antibiotic prophylaxis should only be considered after consultation with the patient and orthopedic surgeon.

Question 58

Prophylactic Regimens

Answer 58

Prophylactic Regimens: Single dose 30-60 min before procedure Amoxicillin (Amoxil®) of 2 g Azithromycin (Zithromax®) of 500 mg Clarithromycin (Biaxin®) of 500 mg

Question 59

clindamyacin prophylaxis?

Answer 59

Clindamycin is no loner recommended for dental procedure antibiotic prophylaxis due to more frequent and serious adverse effects associated with clindamycin compared to other prophylactic options, including C. difficile infections.

Question 60

Other Considerations of prophylaxis? * grafting? * implants?

Answer 60

* Consider 1 week of antibiotic use following bone and soft tissue grafting * Antibiotic prophylaxis before implant placemen