Table 401
Antibiotic Therapy in the treatment of Refractors or Kapidly Progressive Periodontitis
Associated Microflora
Gram-positive organisms
Gram-negative organisms Nonoral gram-negative facultative rods Pseudomonads, staphylococci Rlack-pigmented bacteria and spirochetes Prevo t el la in I er media,
Porphyromonas gingivolis A. octinomycetemcomitans
P, gingivals
Antibiotic of Choice
Amoxicillin-clavulanate potassium (Augmentin)" '1 Clindamycin1 M>nH Ciprofloxacin
Metronidazole'' w
Tetracyclineiu
Metronidazole/
amoxicillin'139 Metronidazole/Ciprofloxacin Tetracycline20-'® Azithromycin"'
S60 PART 5 ■ Treutuwul of I'dtothMtal Disease to the frequent use of this antibiotic.1'*2'1,42-44 Tetracycline-resistant bacteria containing the let m gene for resistance have been isolated from patients with refractory periodontitis.-1* However, some patients with refractory periodontitis may still benefit from the use of tetracycline or one of its derivatives.
t tises of refractory periodontitis in which the associated microflora consists primarily of gram-positive microorganisms have been successfully treated with amoxicillin-clavulanate potassium. Many efforts have been made to establish the most appropriate regimen of antibiotic therapy for these patients. Similar antimicrobials, consisting of 250 mg amoxicillin and 125 mg potassium clavulanale, have been administered three times daily-tor 14 days along with scaling and root planing and produced a reduction in attachment loss for at least 12 months. A regimen of one capsule containing the same amount of drug every 6 hours lor 2 weeks, with intrasul-cular tull-mouih lavage with a 10% povidone-iodine solution and chlorhexidine mouthwash rinses twice daily, showed a reduction in attachment loss that persisted .it approximated 34 months." A regimen of 500 mg metronidazole three times daily for 7 days was shown to be effective in treating refractory periodontitis in patients who were culture positive for Haclcroittes forsythus in the absence ol A. uitinoniyceteimoniituns.^
Clindamycin is a potent antibiotic that penetrates well into gingival fluid, although it is not usually effective against ihtinatnyceieinciHuituns and T.ikenellu eorro-i/mv." However, it has been demonstrated to be effective in controlling the extent and rate of disease progression in refractory cases in patients who have a microflora susceptible to this antibiotic.11 n A regimen of clindamycin hydrochloride 150 mg four times daily for 7 days combined with scaling and root planing produced a decrease in the incidence of disease activity from an annual rate of 8% to 0.5% of sites per patient.11 Clindamycin should be prescribed with caution due to the potential for pseudomembranous colitis from superinfections with ('lostritlium difficilc. Azithromycin may be effective in refractory periodontitis in patients infected with Porphyromonus gingivalis.-'
t ombinations of antibiotic therapy may offer greater promise «is adjunctive treatment lor the management of refractory periodontitis.1'4 I he rationale is based on the diversity ol putative pathogens10 and I he fact that no single antibiotic is bactericidal for all known pathogens. < iomhination antibiotic therapy may help broaden the antimicrobial range ol the therapeutic regimen beyond that attained by any single antibiotic. Other advantages include lowering the dose of individual antibiotics by exploiting possible synergy between two drugs againsi targeted organisms. In addition, combination therapy may prevent or forestall the emergence ol bacterial resistance.
Many combinations of antibiotics (e.g., metronidazole |Augmcnlin| 1 or metronidazole/amoxicillin for the treatment of A. act hunnyivUwcomiUins-associated periodontitis; metronidaz.ole/doxvcycline for the prevention of recurrent periodontitis; metronidazole/ ciprofloxacin1' for the treatment of recurrent cases containing «i microflora associated with enteric rods and pscudomonads; and amoxicillin/cloxycyclinc'1 in the treatment of I. entinontyeetcniconriluus- and/or Porphjft romoitus gingivalis associated periodontitis) have demonstrated significant improvement in the clinical aspects of the disease.M
Some cases of refractory periodontitis may not respond to <i given antibiotic regimen. When this occurs, the clinician should consider «i different antimicrobial therapy based on microbial susceptibility analysis. At this point in the therapy, strong consideration should be given to consulting with the patient's physician for an evaluation of a possible host immune system deficiency or a metabolic problem such «is diabetes.
Although there have been no studies of the treatment ol refractory periodontitis with local delivery systems, it is possible that this method could be used in localized forms of this disease, particularly localized aggressive periodontal diseases. Hie advantage of local therapy is that smaller dosages of topical chemotherapy can be delivered inside the pocket, avoiding the side effects of systemic antibac terial agents. I'he.se local therapies are in the forms of gels, libers, or c hips.H '1
Another approach for treating refractors periodontitis and other forms of periodontal disease is through modulation of the host response by subantimicrobial or nonsteroidal antiinflammatory drugs (NNAIPs) in conjunction with conventional therapy. I he use of low-dose doxycycline may aid in preventing the destruction of the periodontal attachment through controlling the activation of matrix metalloproteinases, primarily collagenase and gelatinase, from both infiltrating arid resident cells of the periodontium, primarily the neutrophils.Other agents such .is llurbipiolen, indomethacin. and naproxen may reduce inflammatory mediator production during chronic periodontal disease.1'1 further research needs to be done to substantiate the effec ts of these agents.
I'he approach to restorative treatment for these patients should be made based on one single premise: Plan fat future tooth loss. I lie teeth with the best prognosis should be identified and considered when planning the restorative work. However, the predic tive v alue of the traditional prognosis categorization can be .is low .is 43% in patients with refractory periodontitis.1 I'he lower cuspids and first premolars are generally more resistant to loss. As a rule, an extensive fixed prosthesis should be avoided, and removable partial dentures should be planned in such a way as to allow for the addition of teeth. The use of dental implants should be considered with great caution. especially in partially edentulous patients.
Although a cause-and-effect relationship has not yet been established between periodontitis and perl-irnplantitis. a relationship between the microflora assod-ated with periodontal and peri-implant pockets, has been described.'u u u Hie combination of implants and periodontally diseased teeth may be possible, but the risks involved should be clearly explained to the patient and avoided until the patient's disease is stabilized.
Aggressive Periodontitis
I he prognosis for patients with aggressive periodontitis (formerly early onset periodontitis» depends on whether
Treatment of Kcfrottorv Periodontitis. A\$ressh'i Pcrhnltmlitis. Necrotizing l-!lceiath\ • ( II AMI IK 40 .561 t'erioitontitis, and Periodontitis AsstKiateil with System'n t >i*icascs the disease is generalized or localized and on the degree of destruction present at the time ol examination. I he generalized forms, which are usually associated with some systemic disease (see Chapter 28), have a worse prognosis than the localized forms. Aggressive periodontitis rarely undergoes spontaneous remission. It is important to obtain earlier radiographs to assess the stage ol the disease.
The following treatments for localized aggressive periodontitis have been attempted in the past, with various degrees of success:
1. Extraction. After the involved teeth, usually the first molars, have been extracted, uneventful healing ensues. The enlargement of the maxillary sinus has been mentioned as an unfavorable sequela that would make future treatment of neighboring teeth difficult/ Transplantation of developing third molars to the sockets of previously extracted lirst molars has also been attempted. 2.Standard periodontal therapy. Such therapy has included scaling and root planing, curettage, Hap surgery with and without hone grafts, root amputations, hemisections. occlusal adjustment, and strict plaque control.u However, response has been unpredictable. Frequent maintenance visits appear to he most important.10 3. Antibiotic therapy. In the late 1970s and early 1980s, the identification ol A. actinoinycetemcoinitans as a major culprit and the discovery that this organism penetrates the tissues clarified the pathogenesis and provided a more solid basis for therapy. Several authors have reported success using antibiotics as adjuncts to standard therapy. Cenco and colleagues10 reported the treatment of localized aggressive periodontitis with scaling and root planing plus tetracycline (250 mg four times daily for 14 days every «S weeks). Measurements of vertical defects were made at intervals of up to IS months after the initiation of therapy. Bone loss had stopped, and one third of the defects demonstrated an increase in bone level, whereas in the control group, bone loss continued.
LUjenberg and I .indite1 R treated patients with localized aggressive periodontitis with tetracycline (250 mg four times daily lor 2 weeks), modified YVidman Haps, and periodic recall visits (one visit every month, for 6 months, then one visit every \ months). The lesions healed more rapidly and more completely than similar lesions in patients with chronic periodontitis. These investigators reevaluated their results after 5 years and found that the treatment had resulted in resolution of gingival inflammation, gain of clinical attachment, and refill of bone in angular defects.1"
Several investigators have noted excellent hone fill in cases of localized aggressive periodontitis treated with tetracycline plus flap surgery and placement of grafts/1'"1" Figs. 40-1 and 40-2 show pretreatment destruction and bone repair in a patient treated hv Harriett and Baker/
The lack of response of juvenile periodontitis to local therapy alone has been interpreted as the result of the presence of A. actinomycdernconiitans in the tissues," iu where it remains after therapy to reinfect the pocket. I he systemic use of antibiotics is needed to eliminate bacteria from the tissues/-'
Current Approach to I herapy. Patients who are diagnosed as having an early form of aggressive periodontitis may respond to standard periodontal therapv In general, the earlier the disease is diagnosed (as deter mined by less destruction), the more conservative the therapy may be and the more predictable the outcome.
In almost all cases, systemic tetracycline (250 mg of tetracycline hydrochloride four times daily for at least I week) should he given in conjunction with local mechanical therapy. If surgery is indicated, systemic tetracv-cline should be prescribed, with the patient instructed to begin taking the antibiotic approximately I hour before surgery. Doxycycline 100 mg/day may also be used. Chlorhexidine rinses should also be prescribed and continued lor several weeks to aid healing and augment plaque control.
In refractory localized aggressive periodontitis cases, tetraeve line-resistant Actinolnhillns species have been suspected. Alter performing antibiotic susceptibility tests, the clinician may consider a combination of amoxicillin and metronidazole, similar to the regimen suggested for refractory periodontitis patients.
Generalized Aggressive Periodontitis
In general the treatment of patients with generalized forms of aggressive periodontitis should be very similar to that of patients with refractory forms of Ihe disease. To date, there are no available data that suggest any alterations in the approach used for refractory forms of the disease.
I he rate ol disease progression inav he faster in these younger individuals, and therefore the clinician should monitor such patients more often. Close collaboration between members ol the treatment team, which includes the periodontist, the general dentist, the dental livgien-ist, and the patient's physician, is required.
It is important to monitor and observe the patient's overall physical status, as weight loss, mental depression, and malaise have been reported in patients with generalized aggressive periodontitis. Similarly, flare-ups of proliferative gingival inflammation can he observed early when the patient is on a frequent monitoring cycle. Currently, monitoring every * weeks or less is suggested while Ihe disease is in an active phase.
Necrotizing Ulcerative Periodontitis
Patients with necrotizing ulcerative periodontitis (Nl'P) are unusual and should he treated in consultation with the physician. As indicated in c hapter 27, these patients often have an underlying predisposing systemic factor that renders the patient susceptible to necrosis of the periodontal structures. It is mandators that these patients be treated aggressively, litis includes a medical evaluation and local, topical, and systemic antimicrobials based on the results ol laboratory tests.
These patients often harbor bacteria, fungi, viruses, and other non-oral microorganisms, making the selection
S ■ liLiiinh'jit of l'erioihmliil t)i\c<isi
Ficj. 40-1 Radiographs depicting progression of the osseous lesion in a case of localized aggressive periodontitis (formerly localized iuvenile periodontitis). A, January 29. 1979; B, August 16, 1979; C, February 22, 1980, D, May IS, 1981 Note Ihe progressive deterioration of the osseous level (From Bar-netl Ml, Baker Rl : The formation and healing of osseous lesions in a patient with localized juvenile periodontitis. Case reporl J Periodontol 1983; 54:148.)
of treatment complicated. Oral hygiene for these patients is complicated by the sometimes painful tissues. In such cases, irrigation with diluted cleansing and antibacterial agents can be of some benefit. The treatment of acquired immunodelicieiK \ syndrome (AlDS)-associated NUP is presented in c hapler 51.
Periodontitis Associated with Systemic Disease
Several systemic diseases appear to predispose the indl* viduals who have them to periodontitis which may be of the aggressive type (see Chapter 28), but which may differ considerably from the aggressive forms described previously. treatment considerations, however, are similar.
- I rciitiiiciit of Kef hicton t'eriodontiiis, Agressive rethhlontitis, \i\roti/ijJg Ulcerative ■ ( II \IM IK 40 563 Vet ¡odont itis. miif l\ iii>th>ntiti\ Asmh 'uiIhI with Svsteniii Diseuses
Fig. 40-2 Postoperative radiographs ot the patient shown in Fig. 40-1 A, November 6, 1981 B, March I, 1982 Treatment consisted of oral hygiene instruction; scaling and root planing concurrently with I g ol tetracycline per day for 2 weeks; and, finally, modified Widman Maps. (From Barnett ML, Baker Rl The formation and healing ol osseous lesions in a patient with localized juvenile periodontitis. Case report. | Peri-odontol 1983; 54:148.)
Fig. 40-2 Postoperative radiographs ot the patient shown in Fig. 40-1 A, November 6, 1981 B, March I, 1982 Treatment consisted of oral hygiene instruction; scaling and root planing concurrently with I g ol tetracycline per day for 2 weeks; and, finally, modified Widman Maps. (From Barnett ML, Baker Rl The formation and healing ol osseous lesions in a patient with localized juvenile periodontitis. Case report. | Peri-odontol 1983; 54:148.)
This includes a medical evaluation and local, topical, and systemic antimicrobials based on the results of laboratory tests. It is mandatory that these patients be treated aggressively.
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