Peridontics : 6/chemotherapeutic Agents In The Treatment Of Periodontal Diseases/ Second Semester

Front 1

Define " Sterilization"

Back 1

Killing or removing all forms of
microbial life (including endospores) in a
material or an object.

Heating is the most commonly used method of
sterilization. ( endospores)

Front 2

define " Disinfection:"

Back 2

Reducing the number of pathogenic
microorganisms to the point where they no
longer cause diseases.

Usually involves the removal of non-endospore
forming pathogens.

Disinfection:
May use physical or chemical methods:

-Disinfectant: Applied to inanimate objects (surfaces
or instruments).

-Antiseptic: Applied to skin or living tissue.

- Degerming: Mechanical removal of most microbes in a
limited area. Example: Alcohol swab on skin.

Front 3

Aseptic techniques

Back 3

are used to prevent
contamination of :
1)surgical instruments, 2)medical personnel, and
3)the patient during surgery.

4)Aseptic techniques are also used to prevent
bacterial contamination in food industry

Front 4

define " Bacteriostatic Agent"

Back 4

An agent that inhibits
the growth of bacteria, but does not
necessarily kill them. (Suffix stasis: To stop or
steady)

Front 5

define " Germicide:"

Back 5

An agent that kills certain
microorganisms.

Bactericide: An agent that kills bacteria.



Viricide: An agent that inactivates viruses.

Fungicide: An agent that kills fungi.

Sporicide: An agent that kills bacterial endospores
of fungal spores.

Front 6

Coal tar distillation

Back 6

• Complex mixture of aromatic
compounds
• These are first separated by
distillation
• Phenol is found in the carbolic
oil and is recovered by further
distillation and washing with
slaked lime (calcium
hydroxide) solution
• Nowadays phenol is produced
by chemical synthesis.

Front 7

Antiseptics & Disinfectants

Back 7

1. Phenols and Phenolics: ( Phenol, Cresols, Biphenols )
2. Halogens: ( Iodine, Chlorine,
3. Alcohols: (Ethanol, Isopropanol:
4. Heavy Metals: (copper, selenium, mercury, silver, and zinc)
5. Quaternary Ammonium Compounds
6. Aldehydes: (Formaldehyde, Glutaraldehyde)
7. Gaseous Sterilizers: (Ethylene Oxide)
8. Peroxygens (Oxidizing Agents):
(Ozone, Hydrogen Peroxide, Benzoyl Peroxide, Peracetic Acid)

Front 8

1-Phenols and ....

Back 8

Phenol (carbolic acid):
-
Rarely used today because it is a skin irritant (caustic ) and has
strong odor.

-Acts as local anesthetic.
-
aromatic alcohol

Front 9

1-and Phenolics:

Back 9

Phenolics (derivatives of phenol)

-Cresols (methyl phenol ): Derived from coal tar.
-
Biphenols : Effective against gram-positive
staphylococci and streptococci.


Excessive use in infants may cause neurological
damage.

Front 10

Phenols and Phenolics:

Back 10

Destroy plasma membranes and denature proteins
(detergent effect).


Advantages: 1)Stable,
2) persist for long times after applied,
and remain active in the presence of organic
compounds.

Front 11

Limitations of Phenol

Back 11

• Phenol is a caustic substance and reacts with
tissue causing damage.

• The maximum concentration permitted in
registered preparations is 1%

• At these concentrations, phenol acts as a
bacteriostat

Front 12

2. Halogens:

Back 12

Effective alone or in compounds

Front 13

Halogens --> A. Iodine

Back 13

-Tincture of iodine (alcohol solution) was one of first
antiseptics used.


-Combines with amino acid tyrosine in proteins and
denatures proteins.

-
Stains skin and tissues, somewhat irritating.


-Iodophors: Compounds with iodine that are slow
releasing, take several minutes to act


-Used as skin antiseptic in surgery


-Not effective against bacterial endospores.

Betadine

Isodine

( the above is for iodine )

Front 14

Halogens --> B. Chlorine

Back 14

When mixed in water forms hypochlorous acid:
Cl2 + H2O ------> H+ + Cl- + HOCl

-Used to disinfect drinking water, pools, and sewage.


- Chlorine is easily inactivated by organic materials.

-
Sodium hypochlorite (NaOCl): Is active ingredient of
bleach.

-
Chloramines: (chlorine and ammonia)
Less effective as germicides.

Front 15

3. Alcohols

Back 15

Bacteria, fungi, but not endospores or naked
viruses.


Act by denaturing proteins and disrupting
cell membranes.


Used to mechanically wipe microbes off skin
before injections or blood drawing.


Not for open wounds, (protein coagulation)


-Ethanol: Optimum concentration is 70%.


- Isopropanol: Rubbing alcohol
Better disinfectant than ethanol (cost and less
volatile.)

Front 16

4.Heavy Metals

Back 16

Include copper, selenium, mercury, silver, and zinc.


Oligodynamic action: Very tiny amounts are
effective.

Front 17

Heavy Metals --> silver

Back 17

1% silver nitrate used to protect infants against
gonorrheal eye infections until recently.

Front 18

Heavy metals --> Mercury

Back 18

Organic mercury compounds like merthiolate and
mercurochrome are used to disinfect skin wounds.

Front 19

Heavy Metals --> Copper

Back 19

Copper sulfate is used to kill algae in pools and fish
tanks.

Front 20

Heavy metals --> Selenium

Back 20

Used for fungal infections.

Front 21

heavy metals --> Zinc

Back 21

Zinc chloride is used in mouthwashes.

Zinc oxide is used as antifungal agent in paints.

Front 22

5. Quaternary Ammonium Compounds:

Back 22

Widely used surface active agents.


Cationic (positively charge) detergents.


Effective against gram positive bacteria, less effective
against gram-negative bacteria.


Also destroy fungi, and enveloped viruses.

Front 23

Quaternary Ammonium Compounds examples

Back 23

Zephiran in lab spray bottles.

Pseudomonas strains that are resistant and can grow
in presence of Quats are a big concern in hospitals

Advantages: Strong antimicrobial action, colorless,
odorless, tasteless, stable, and nontoxic.

Diasadvantages: 1)Form foam. Organic matter
interferes with effectiveness.


2)Neutralized by soaps and
anionic detergents.

Front 24

6. Aldehydes:

Back 24

Include some of the most effective antimicrobials.


Inactivate proteins by forming covalent crosslinks
with several functional groups.

Front 25

Aldehydyes --> A. Formaldehyde gas:

Back 25

Excellent disinfectant.


Commonly used as formalin, a 37% aqueous solution.


Formalin was used extensively to preserve biological
specimens and inactivate viruses and bacteria in
vaccines.


Irritates mucous membranes, strong odor.

Front 26

Aldehydes --> B. Glutaraldehyde:

Back 26

Less irritating and more effective than formaldehyde.


One of the few chemical disinfectants that is a
sterilizing agent.


A 2% solution of glutaraldehyde is:
-Bactericidal, tuberculocidal, and viricidal in 10 minutes
Sporicidal in 3 to 10 hours

Commonly used to disinfect hospital instruments

Front 27

7.Gaseous Sterilizers:

Back 27

Chemicals that sterilize in a chamber similar to an
autoclave.


Denature proteins, by replacing functional groups with
alkyl groups.

Front 28

Gaseous sterlizers --> A. Ethylene Oxide

Back 28

Microbes and endospores,


Requires exposure of 4 to 18 hours.


Toxic and explosive in pure form.


Highly penetrating.


Most hospitals have ethylene oxide chambers to
sterilize mattresses and large equipment.

Front 29

8.Peroxygens (Oxidizing Agents)

Back 29

Oxidize cellular components of treated microbes.


Disrupt membranes and proteins.

Front 30

preoxygens --> A. Ozone

Back 30

Used along with chlorine to disinfect water.


Helps neutralize unpleasant tastes and odors.


More effective killing agent than chlorine, but less
stable and more expensive.


Highly reactive form of oxygen.

Made by exposing oxygen to electricity or UV light.

Front 31

preoxygens --> B. Hydrogen Peroxide

Back 31

Used as an antiseptic.


Not for open wounds because quickly broken down by
catalase present in human cells.


Effective in disinfection of inanimate objects.

Sporicidal at higher temperatures.

Front 32

preoxygens --> C. Benzoyl Peroxide:

Back 32

Used in acne medications.

Front 33

preoxygens --> D. Peracetic Acid

Back 33

One of the most effective liquid sporicides available.


Sterilant : ( adjv. )
-
Kills bacteria and fungi in less than 5 minutes.
-Kills endospores and viruses within 30 minutes

Used widely in disinfection of medical instruments
because it does not leave toxic residues.

Front 34

Effectiveness of antimicrobial
treatment has the following factors :

Back 34

1. Number of Microbes: The more microbes present,
the more time it takes to eliminate population.

2. Type of Microbes: Endospores are very difficult to
destroy. Vegetative pathogens vary widely in
susceptibility to different methods of microbial control.

3. Environmental influences: Presence of organic
material (blood, feces, saliva) tends to inhibit
antimicrobials, pH etc.

4. Time of Exposure: Chemical antimicrobials and
radiation treatments are more effective at longer times.
In heat treatments, longer exposure compensates for
lower temperatures.

Front 35

What's the rationale for anti-plaque agents ?

Back 35

• Mechanical removal of plaque:
- Time consuming
- Affected by: gingival architecture, Tooth position,
Dexterity, Motivation

Incomplete removal of plaque by mechanical
means will cause progression and induction of
periodontal diseases and caries..

Front 36

The Antimicrobial Approachs

Back 36

1. Mouth Rinses
2. Dentifrices
3. Subgingival Irrigation
4. Controlled Release
5. Systemic Antibiotics
6. Host Modulation Drugs
7. Photodisinfection

Front 37

What ways can we use anti-plaque agents ?

Back 37

1) to interfere witht he adhesion of oral bateria to surface and prevent biofilm formation

2) to interfere with co-aggreation mechansims or to affect bacterial vitailtiy which therby prevent further growth of colonies

3) to remove or disrupt existing biofilms

Front 38

What are the ideal proprites for anti-plaque agents ?

Back 38

Specificity for pathogenic bacteria

Prevent development of drug resistance.

Efficacy:
- Decrease plaque formation and gingivitis.
- Inhibit overgrowth of other organisms
- Inhibit mineralization of plaque to calculus.

• Safety :
- Non toxic, non allergic and non irritating for oral
tissues and teeth.
- Limited systemic absorption

Acceptable taste, flavor and color.

Low cost, available and easy to use.

High substantivity

Front 39

Classify the anti-plaque agents

Back 39

1)Cationic surfactant (+ve charged) :
A)Bisbiguanids
-Chlorhexidine gluconate

B) Quaternary ammonium compound :
-Benzalkonium chloride

2)Anionic surfactant (-ve charged) :
-Na lauryl sulphate.

3) Enzymes :
-Mucinase
-Mutanase

4) Phenolic compound :
-Triclosan.
-*Listerine.

5) Herbal extracts :
-Sanguinarine.

6) Others :
Povidone iodine

Front 40

Chlorhexidine

Back 40

It is a cationic surfactant

• Chlorophenyl bisbiguanids

• It has both disinfectant and
antiseptic properties.

• It has also bactericidal and
bacteriostatic in nature.

Front 41

describe the Chlorhexidine Mechanism of action ( part 1)

Back 41

It binds with teichoic acid in gram positive bacteria
and lipopolysaccharide in gram negative bacteria.

– Broad spectrum bactericidal agent

– High substantivity
• Binds to oral tissues
• Released in active form for up to 5 hours

– Ruptures bacterial cell membrane releases
cytoplasm contents

– Reduces adherence capacity of P.gingivalis

Front 42

Antiplaque action of chlorhexidine (part 2)

Back 42

1. Prevents pellicle formation by blocking acidic
groups on salivary glycoproteins thereby
reducing glycoprotein adsorption on to the
tooth surface

2. Prevents adsorption of bacterial cell wall on to
the tooth surface

3. Prevents binding of mature plaques

Front 43

what are the side effects of cholorhexidine ?

Back 43

– Extrinsic brown staining
– Increase in supragingival calculus
accumulation
– Alteration in taste perception (temporary)
– Bitter taste
– Mucosal desquamation

Front 44

List the indications for using systemtic antibitoits

Back 44

Not for Gingivitis and Chronic Periodontitis

• Selectively for Aggressive Periodontitis

• Selectively for some cases of chronic Periodontitis

• Side-effects (Antibiotic resistance)

Front 45

List the common antibitoic therpies for aggresive peridontits

Back 45

Tetracyclin (250mg /4days/12-14days)

Metronzidole (500mg/3 times / day / 7 days )

Doxycyeline (200mg /1 time / followed by 400 mg / per day for 14 days )

meterodizoale and amoxicillin (250mg + 375 mg of amoxiallicn 3/daily for 7 days )

meteriodizole and cripofloxin (500mg of each drug twice a day for 8 days )

Front 46

Single application of in-office subgingival
irrigation with an antimicrobial agent has
been shown to have only limited or no
beneficial effects over periodontal
instrumentation alone, true or false ?

Back 46

TRUE

Front 47

Irrigation with Water

Back 47

Irrigation with water provides an
equally beneficial effect as
irrigation with an antimicrobial
Agent !!!!

Front 48

Subgingival Irrigation

Back 48

• Subgingival irrigation performed
before periodontal instrumentation:
-- reduce the incidence of bacteremia
-- reduce the number of microorganisms in
aerosols

Front 49

Controlled Release Agents

Back 49

Rationale:
“substantivity” for sustained & therapeutic dose

Consider in specific sites & situations

Available Products:
-Tetracycline fibers / Minocycline microspheres /|
-Doxycycline Hyclate gel / Chlorhexidine chip

Front 50

PerioChip

Back 50

• Description:
– Contains 2.5 mg Chlorhexidine gluconate
– Biodegradable matrix of hydrolyzed gelatin

Front 51

Photodisinfection

Back 51

• Photosensitive compound
(methylene blue

• Selectively binds to
periodontal pathogens

• Using diode laser (670nm

Excitation Redox
reaction (oxygen species)

Front 52

Host Modulation Drugs

Back 52

1)NSAIDS :
• Prostaglandins are important in the
pathogenesis of periodontal disease

• NSAIDS inhibit prostaglandin synthesis

• NSAIDS may slow periodontal bone loss

NSAIDS may reduce gingivitis

2) Tetracycline :
• Tetracycline can inhibit the activity of host
derived collagenases, gelatinase & elastase

• Some studies have shown clinical
improvement attributed to the anticollagenase
effect rather than the
antibacterial effect

Front 53

How to write a
prescription?

Back 53

• Write clearly

• Preferably use scientific name

• Write the form of medication

• Write the quantity of the medication

• Write the method of application

• Write the duration of intake

• Write the doze

• Write the precautions

• Use accurate abbreviations

Front 54

Form of medication

Back 54

• Oral Route: Capsules, syrup, tablets…

• Intra-oral topical use: Rinses, lozenges,
ointment, gel

• External use: ointment, gel, cream…

• Injections: intra-muscular (IM), intravenous
(IV), subcutaneous (SC)

Front 55

Quantity prescribed

Back 55

Specially in restricted medications !!

• For pain medications (30 tab, 20 caps)…

• Know the proper dosage to know the
proper quantities. Example: Amoxicillin is
prescribed for intra-oral infections for one
week, three times daily

• 7 X 3 = 21 capsules

• Children syrup: know the concentration
per ml. and the child weight

• Medications and doses that require less
compliance, especially for long-term use

Front 56

Abbreviations commonly used

Back 56

• b.i.d.: used twice daily (every 12 hours)
• t.i.d.: three times daily (every 8 hours)
• q.i.d.: four times daily
• h.s.: at bed time
• Stat.: immediately
• d.: once daily
• p.c.: after meal
• p.r.n.: when needed
• Caps.=capsules
• tab= tablets

Front 57

Examples: amoxicillin

Back 57

Prescribed for adults as 250 mg and 500
mg capsules
Amoxicillin 500 mg caps (22
caps)
2 stat then 1 x 3 x 7 p.c. OR;
2 stat then 1 t.i.d. p.c. 7 days

Front 58

Examples of commonly used
medications in dentistry:
Pain

Back 58

• Ibuprofen
– Syrup (for children)
– Tablets (200, 400, 600, 800 mg), or
gelcap (Doloraz 400)
– Maximum dose per day for healthy adult:
2400 mg per 24 hours
– Prescribed t.i.d.
– Post surgery: depending on severity 400-
800 t.i.d. p.c.

• Paracetamol (acetomenophin)
– Children: syrup, supps

– Adults: tablets 250, 500, 1000 mg, effervescent tablets
– Could come with caffiene or combination of aspirin
and caffiene (Tylenol preps, USA)

– New fast release: Panadol Actifast (500 mg)

– Maximum dose per day for healthy adult: 4 grams per
24 hours

– Helpful for patients with gastric irritation, asthma,
contraindications for NSAIDs.

Front 59

examples

Back 59

Examples:
– Ibuprofen 400 mg tabs 30
– 1-2 tab t.i.d. p.r.n. p.c.
– Or; 1-2 tab x 3 p.r.n. p.c.
– Paracetamol 500 mg tabs 40
– 1-2 tab q.i.d. p.r.n. p.c.
– Or, 1-2 x 4 x 3 then p.r.n.

Front 60

Chlorhexidine gluconate mouthwash
(mouth rinse)

Back 60

European preps (BP, 0.2%), US preps (USP, 0.12%)

• Prescribed post-surgical, for patients with challanging
oral cavity conditions, severe inflammation, physicallyimpaired
patients, nifedipine-induced gingival
enlargement and patients with poor mechanical ability
to remove calculus)

• The duration and frequency of use not agreed upon
(days depend on indication)

• Common prescription in our clinic is b.i.d. rinse

Front 61

Chlorhexidine gluconate mouthwash
(mouth rinse) example

Back 61

• Chlorhexidine 0.2% mouthwash I bottle
• Rinse 2 minutes, 30 minutes after
brushing
• 10 ml x 2x 14

Front 62

Antibitoics

Back 62

• Many, many…
• Periodontics: aggressive peridontitis
– For adults: amoxicillin 500 mg caps (2 stat)
and Metronidazole 250 mg tabs (t.i.d. p.c. 7
days)
– Or Doxycycline 100 mg (2 stat then 1X1X20)