A alveolite seca é uma das complicações pós-operatórias mais comuns e sintomáticas na exodontia, porém, até o momento não possui um protocolo de tratamento definido. A oxitetraciclina (OTC) é um antibiótico de amplo espectro utilizado no tratamento de múltiplas infecções. Entretanto, nos últimos anos as tetraciclinas de primeira geração, tais como a OTC, têm sido evitadas devido ao surgimento de microrganismos resistentes. Afortunadamente, nos últimos anos tem se observado uma tendência contrária graças às medidas de controle no uso de antibióticos. Sistemas de liberação controlada podem evitar o desenvolvimento de resistência bacteriana e diminuir o risco de efeitos adversos. Este estudo teve como objetivo preparar uma nanofibra polimérica de policaprolactona e oxitetraciclina (PCL/OTC), e ainda avaliar suas propriedades físicas e biológicas in vitro e in vivo, visando seu futuro uso no tratamento da alveolite seca. As nanofibras poliméricas carregadas com OTC foram preparadas pelo sistema de eletrofiação, caracterizadas através da microscopia eletrônica de varredura (MEV) e avaliadas sobre seu perfil de liberação do fármaco. A atividade antibacteriana da nanofibra sobre um biofilme misto de Porphyromonas gingivalis, Prevotella intermédia, Fusobacterium nucleatum, Eikenella corrodens, Streptococcus sanguis e Aggregatibacter actinomycetemcomitans foi analisada mediante a contagem das unidades formadoras de colônias viáveis após os tempos de contato de 1, 4, 24, 30 e 48 h. O processo de reparo alveolar induzido pela nanofibra PCL/OTC foi avaliado de forma histomorfológica e histomorfométrica após o tratamento da alveolite seca em molares de ratos, e comparado ao tratamento com nanofibras de PCL pura e Alvogyl®, 7, 14 e 21 dias após a exodontia. Finalmente, foi realizada a identificação e contagem de osteoclastos através da marcação da fosfatase ácida resistente ao tartarato (TRAP), nos mesmos tempos de avaliação. As nanofibras PCL/OTC apresentaram orientação randômica em camadas e morfologia multiforme. O perfil de liberação do sistema apresentou um efeito de explosão nas primeiras 8 horas, seguido por um período de liberação lenta e prolongada da OTC. A nanofibra PCL/OTC (132 ?g de OTC/mL) reduziu mais de 50% das colônias do biofilme nas primeiras horas de liberação, seguido por um período de manutenção em que a porcentagem de colônias bacterianas permaneceu baixa. O grupo tratado com PCL/OTC apresentou a maior porcentagem de tecido conjuntivo no 7º dia (p<0,05) e maior porcentagem de osso neoformado no 14º e 21º dias após a exodontia (p<0,05), em comparação aos outros grupos. O tratamento de alveolite seca com a fibra PCL/OTC permitiu a regeneração tecidual do alvéolo quase em sua totalidade até o 21º dia, sendo que a cronologia de regeneração tecidual com este material foi mais rápida do que com a fibra de PCL pura, e esta última mais rápida que do que o controle positivo Alvogyl®. O grupo PCL/OTC apresentou uma quantidade menor (p<0,05) de osteoclastos por área em relação aos outros grupos nos três tempos experimentais. O perfil de liberação prolongando de OTC e as propriedades biológicas relevantes apresentadas pela nanofibra PCL/OTC, sugerem que esta poderia ser considerada uma alternativa para o tratamento da alveolite seca. / Dry socket is one of the most common and symptomatic postoperative complications in tooth extraction, however, to date, it does not have an established treatment protocol. Oxytetracycline (OTC) is a broad-spectrum antibiotic, employed in the treatment of multiple infections. Nevertheless, in the last few years, first-generation tetracyclines such as OTC, have been avoided due to the development of resistant microorganisms. Fortunately, in recent years there has been a contrary trend thanks to control measures in the use of antibiotics. Controlled release systems can prevent the development of bacterial resistance and decrease the risk of adverse effects. This study aimed to prepare a polymeric nanofiber of polycaprolactone and oxytetracycline (PCL/OTC), and to evaluate its physical and biological properties in vitro and in vivo, aiming its use in the treatment of dry socket at the future. The OTC-charged polymeric nanofibers were prepared by electrospinning, and characterized by scanning electron microscopy (SEM) and drug release profile evaluation. The antibacterial activity of the nanofiber over a mixed biofilm containing Porphyromonas gingivalis, Prevotella intermedia, Fusobacterium nucleatum, Eikenella corrodens, Streptococcus sanguis, and Aggregatibacter actinomycetemcomitans was analyzed by counting the viable colony-forming units after 1, 4, 24, 30 and 48 h of contact. The alveolar repair process induced by the PCL/OTC nanofiber was evaluated histomorphologically and histomorphometrically after the treatment of dry socket in rat molars, and compared to the treatment with plain PCL nanofibers and AlvogylTM, 7, 14 and 21 days after extraction. Finally, the identification and counting of osteoclasts were performed through the tartrate resistant acid phosphatase (TRAP) staining, at the same evaluation time points. PCL/OTC nanofibers presented random orientation in layers and multiform morphology. The release profile of the PCL/OTC system showed a burst effect within the first 8 hours, followed by a prolonged slow release period. The PCL/OTC nanofiber at a concentration of 132 ?g OTC/mL reduced more than 50% of the biofilm colonies in the first few hours of release, followed by a maintenance period in which the percentage of bacterial colonies remained low. The PCL/OTC group presented the highest percentage of connective tissue on the 7th day (p<0.05), and of newly formed bone on the 14th and 21st days (p<0.05) after dental extraction, compared to the other groups. The treatment of dry socket with the PCL/OTC fiber allowed almost complete tissue regeneration up to the 21st day, and the chronology of tissue regeneration with this material was faster than with the plain PCL fiber, and the latter was more rapid than the positive control AlvogylTM. The PCL/OTC group presented a lower amount (p<0.05) of osteoclasts per area than the other two groups in the three experimental periods. The prolonged release profile of OTC and the relevant biological properties presented by the PCL/OTC nanofibers suggest that these may be considered as an alternative treatment of dry socket.

Indiana University-Purdue University Indianapolis (IUPUI) Endodontic Regeneration Graduate Endodontic Department / Introduction: Regenerative endodontic procedures are used to treat immature teeth with pulpal necrosis in order to control infection, enable continued root development and enhance formation of a pulp like tissue in the canal. Canal disinfection is an integral part the regenerative endodontic process. Double antibiotic paste (DAP; i.e., equal parts of ciprofloxacin and metronidazole) has been successfully used for canal disinfection in regenerative endodontics. A comparison of the residual antibacterial effect of dentin treated with various dilutions of DAP pastes on biofilm formation has not yet been investigated thoroughly. Objectives: The aims of this in-vitro study were to investigate how concentration and time of treatment affect the residual antibacterial properties of DAP in preventing E. faecalis biofilm formation on human dentin. Materials and Methods: Extracted human teeth were used to obtain 4x4mm radicular dentin specimens. Each specimen was pretreated for 1 or 4 weeks with the 77 clinically used concentration of DAP (500 mg/mL), low concentrations of DAP (1, 5 or 50 mg/mL) loaded into a methylcellulose system, calcium hydroxide (Ca(OH)2), or placebo paste. After treatment, samples were rinsed and placed in sterile phosphate buffered saline (PBS) for three weeks. Samples were then inoculated with cultured E. faecalis and incubated in anaerobic conditions for three weeks to allow mature biofilm formation. The dentin samples were rinsed and biofilms detached. The detached biofilm cells were then diluted and spirally plated for enumeration on blood agar plates. The plates were then incubated for 24 h and the number of CFUs/mL was determined using an automated colony counter. Data was analyzed using Fisher’s Exact and Wilcoxon rank sum tests were used for statistical comparisons (α=0.05). Results: Dentin pretreatment for 4 weeks with 5, 50 or 500 mg/mL of DAP demonstrated significantly higher residual antibacterial effects and complete eradication of E. faecalis biofilms in comparison to a 1 week pretreatment with similar concentrations. However, dentin pretreated with 1 mg/mL of DAP or Ca(OH)2 did not provide a substantial residual antibacterial effect regardless of the application time. Conclusion: Dentin treated with 500, 50, or 5 mg/mL of DAP for 4 weeks was able to completely prevent the colonization of bacterial biofilm. Four-week treatment of dentin with DAP offers superior residual antibacterial effect in comparison to a one-week treatment. Intracanal application of DAP for 4 weeks during endodontic regeneration may offer an extended residual antibacterial effect.

Indiana University School of Dentistry Department of Endodontics / Introduction: Triple antibiotic paste (TAP, 1000 mg/ml) is composed of equal portions of ciprofloxacin, metronidazole and minocycline and is used as an intracanal dressing to disinfect the infected immature root canal during endodontic regeneration procedures. Lower concentrations of TAP have been recommended to minimize detrimental effects on pulp stem cells. TAP can be retained within the dentin matrix and its continual release confers an antibacterial effect to the dentin. Objective: The aim of this in vitro study was to investigate the residual antibacterial effect of dentin treated with various concentrations of TAP loaded into a gel system. Materials and Methods: Radicular dentin slabs were prepared from human teeth after obtaining IRB approval. The slabs were sterilized and treated with methylcellulose-based TAP of 100 mg/mL, 10 mg/mL, 1 mg/mL, 1.5% NaOCl, placebo paste with no TAP, or a positive control group with pure 1000 mg/mL TAP. Samples in each group were treated with the assigned TAP concentration for three weeks or immersed in 1.5% NaOCl for five minutes (n =18 per group). All samples were then irrigated with sterile water followed by 17% EDTA and incubated in phosphate buffered saline for either 2 or 4 weeks. Samples were then inoculated with Enterococcus faecalis and incubated for an additional 3 weeks. Biofilm formed on each sample was then dislodged and spiral plated to evaluate the bacterial colony-forming units. Data were analyzed using Fisher’s Exact tests and Wilcoxon rank sum tests (α = 0.05). Results: Dentin treated with 10, 100, or 1000 mg/mL of TAP demonstrated significant residual antibacterial effects up to four weeks. However, only 100 mg/mL TAP was able to completely prevent bacterial colonization after four weeks. No considerable residual antibacterial effect was observed in dentin treated with placebo gel, 1 mg/ml TAP or 1.5% NaOCl. Conclusion: At least 10 mg/mL of TAP loaded into a methylcellulose system is required to achieve a substantial residual antibacterial effect for four weeks.

Indiana University-Purdue University Indianapolis (IUPUI) Indiana University School of Dentistry Indiana University Endodontic Department / The residual antibacterial effects of antimicrobials used in endodontic regeneration against biofilm bacteria obtained from immature and mature teeth Jordon C. Jacobs DDS, Richard L Gregory PhD, Ygal Ehrlich DMD, Kenneth Spolnik DDS, MS, Josef S. Bringas DMD, DDS, MS, and Ghaeth Yassen BDS, MSD, PhD We explored the residual antibacterial properties of dentin pretreated with low concentrations of double antibiotic paste (DAP) against biofilm bacteria obtained from different clinical sources. Dentin blocks were sterilized and randomized into 4 treatment groups and 2 control groups (n=20). Blocks from treatment groups were pretreated with DAP (1 or 5 mg/ml) loaded into methylcellulose, calcium hydroxide (Ca(OH)2), or methylcellulose paste. After one week, the treatment pastes were removed and all blocks were immersed in PBS. The dentin blocks from treatment groups and one of the control groups were then inoculated with bacterial isolates obtained from immature or mature teeth with pulpal necrosis(n=10). The remaining control group received no bacteria and was used as a sterile control. Blocks were then incubated anaerobically for 3 weeks. Biofilm disruption assays were conducted for all samples. Two-way ANOVA and pair-wise comparisons were used for statistical analyses. The residual antibacterial effect of dentin pretreated with 5 mg/ml of DAP was significantly higher than all other groups regardless of the source of biofilm. Dentin pretreated with 1 mg/ml of DAP demonstrated significantly higher residual antibacterial effects in comparison to dentin pretreated with placebo paste and Ca(OH)2 only in bacterial isolates obtained from mature teeth with pulpal necrosis. Dentin pretreated with Ca(OH)2 did not demonstrate any residual antibacterial effects. Dentin pretreated with 1 or 5 mg/ml of DAP demonstrated significantly better residual antibacterial effects against biofilm bacteria obtained from mature teeth with pulpal necrosis in comparison to bacterial isolates obtained from immature teeth with pulpal necrosis.

We investigated the antibacterial effect of low concentrations of double antibiotic paste (DAP) loaded into a methylcellulose system against bacterial biofilms obtained from mature and immature teeth with necrotic pulps. Standardized radicular dentin specimens were randomly divided into six experimental groups (n = 20). Group 1: 5mg/mL DAP treatment. Group 2: 1mg/mL DAP treatment. Group 3: Calcium hydroxide (Ca(OH)2) treatment. Group 4: Methylcellulose. Group 5: No treatment. Group 6: No bacteria or treatment. Clinical bacterial isolates were obtained from mature and immature teeth with necrotic pulps indicated for endodontic regeneration or routine endodontic treatment, respectively. Specimens in each group were inoculated with either bacterial isolates (n = 10) and incubated anaerobically for 3 weeks. Specimens were then treated for one week with the assigned group treatment. Treatments were rinsed with sterile saline and biofilms were detached and spiral plated using biofilm disruption assays. Wilcoxon Rank Sum tests followed by pair-wise comparisons were used for statistical analyses. Treatment of infected dentin with 1 mg/ml of DAP, 5 mg/mL of DAP, and Ca(OH)2 demonstrated significant and substantial antibiofilm effects in comparison to untreated control groups or groups treated with placebo paste. Furthermore, 1 mg/mL of DAP caused complete eradication of biofilm obtained from mature tooth with necrotic pulp. However, the same concentration was not able to completely eradicate biofilm obtained from the immature tooth with necrotic pulp. Low concentrations of DAP (1-5 mg/mL) loaded into a biocompatible methylcellulose system demonstrated significant antibacterial effects against biofilm obtained from both mature and immature teeth with necrotic pulps.

Indiana University-Purdue University Indianapolis (IUPUI); Graduate Endodontics, Masters degree thesis / We evaluated the antibacterial stability (shelf life) of a new radiopaque double antibiotic paste (RoDAP) loaded in a methylcellulose system with 30% w/v barium sulfate against biofilm collected from an immature tooth with necrotic pulp. Uniform radicular dentin specimens were infected with bacterial biofilm obtained from an immature tooth with a necrotic pulp and incubated anaerobically for three weeks. These samples were randomly divided into 6 experimental groups (n=7) and treated for 1 week at three time points of aged radiopaque DAP: 0 months, 3 months, and 6 months. Group 1: 1mg/mL RoDAP treatment. Group 2: 10 mg/mL RoDAP treatment. Group 3: Calcium hydroxide (Ca(OH)2) treatment. Group 4: Methylcellulose with barium sulfate. Group 5: No treatment. Group 6: No bacteria or treatment. The samples were rinsed with sterile saline to detach biofilms and then spiral plated using a biofilm disruption assay. Statistical analyses were performed using Wilcoxon rank-sum tests and Wilcoxon signed rank tests with fixed effects for treatment, time, and the treatment-by-time interaction. Treatment of infected dentin with 1 mg/mL RoDAP, 10 mg/mL RoDAP, and Ca(OH)2 demonstrated significant and substantial antibiofilm effects in comparison to untreated control groups or groups treated with placebo paste after 0, 3, and 6 months of aging. Calcium hydroxide, however, showed slightly less antibiofilm activity after 6 months of aging when compared to 0 months and 3 months of aging. This difference was statistically significant (p > 0.05). In conclusion, both concentrations of RoDAP maintained full antibacterial efficacy after 6 months of aging, while calcium hydroxide lost some antibacterial activity after a shelf life of 6 months.

Indiana University-Purdue University Indianapolis (IUPUI) / Introduction: Regenerative endodontic procedures require adequate disinfection of immature teeth with necrotic pulps. Regeneration endodontic procedures have been shown to increase width and length of dentin after disinfection of the root canal system with various antibiotic pastes such as double antibiotic paste (DAP). DAP is composed of an equal ratio of metronidazole and ciprofloxacin. After the root canal system is disinfected with DAP, it is later flushed out with 17-percent EDTA. There is a need for a radiopaque component in the DAP to facilitate proper placement. Following disinfection with DAP, a residual antibacterial effect is formed in dentin. It is not known if this effect is modified by making DAP radiopaque. Objectives: The residual antibacterial effects of a radiopaque double antibiotic paste against a bacterial isolate obtained from an immature tooth with necrotic pulp on radicular dentin will be explored utilizing various strengths of DAP (1 mg/mL, 10 mg/mL, and 25 mg/mL) after 1 week and 4 weeks. Materials and Methods: Dentin samples of 4x4-mm will be prepared from previously extracted human posterior teeth. The samples will be assigned to seven treatment groups in a random fashion (G1 will be treated with 25-, G2-10, and G3-1 mg/mL of radiopaque DAP. G4 will be treated with the radiopaque filler without DAP. G5 will be treated with Ca(OH)2 and G6 sterile water with bacterial biofilm, and G7 will be sterile water). The groups will be treated for both 1 week 4 weeks. These samples will then be stored in a phosphate buffered saline (PBS) solution for 1 week and then inoculated with the cultured bacterial isolate from an immature tooth with necrotic pulp. The specimens will be incubated for three weeks to permit adequate formation of a biofilm. The biofilm will be detached, diluted and spirally plated onto blood agar plates and incubated for a total of 48 hours in 5-percent CO2 at 37°C. The number of CFUs/mL will be counted using an automated colony counter. A two way ANOVA and Fisher’s Protected Least Significant Differences test using 5-percent significance level will be used to evaluate the resulting data. Expected outcome: A residual antibacterial effect will be observed on radicular dentin samples when treated with radiopaque DAP. Conclusion: Using a radiopaque DAP that provides residual antibacterial effects, further awareness into regenerative endodontic procedures will be gained leading to alterations in treating such cases. / 2020-06-30

Diss. (sammanfattning) Linköping : Linköpings universitet, 2005. / Härtill 5 uppsatser.

Diss. Linköping : Linköpings universitet, 2007.

Introdução: Reação Adversa a Medicamento (RAM) é qualquer resposta prejudicial ou indesejável e não intencional que ocorre com medicamentos em doses normalmente utilizadas no homem para profilaxia, diagnóstico, tratamento de doença ou para modificação de funções fisiológicas. Atualmente, representa uma das principais causas de morbidade e mortalidade na área da saúde. Objetivo: Analisar as reações adversas a medicamentos e fatores associados em pacientes ortopédicos tratados com antibióticos. Método: Coorte prospectiva conduzida com 273 pacientes ortopédicos internados no Instituto Nacional de Traumatologia e Ortopedia, Rio de Janeiro, Brasil. A coleta de dados ocorreu nos anos de 2012 e 2013, por meio de instrumento composto por variáveis demográficas-clínicas e terapia medicamentosa. Para identificação das RAMs realizou-se o monitoramento ativo, composto de: entrevista, análise de prontuários e exames laboratoriais. As RAMs consideradas graves foram analisadas por meio do formulário do Instituto Catalão de Farmacologia, Espanha. Na análise dos dados utilizaram-se os testes Mann-Whitney, Qui-Quadrado, exato de Fisher e regressão logística, com significância de p 0,05. Resultados: A incidência de RAM foi de 41%. O grupo com RAM apresentou maior média de idade (43,3; DP 10,9), tempo de internação (72,7; DP 40,9) e número de medicamentos concomitantes (13,2; DP 4,1). Os fatores associados foram número de medicamentos, uso de antimicobacteriano (OR 2,44; IC 1,3944,270) e carbapenêmicos (OR 2,38; IC 1,167 4,872). Identificaram-se 466 RAM, cuja maioria (67,1%) foi classificada como leve. No grupo de pacientes com RAMs graves identificaram-se leucopenia (46,6%), insuficiência renal aguda (40%) e hepatite medicamentosa (26,6%). Os antibióticos foram os principais medicamentos suspeitos de causar as RAMs graves (76,4%), sendo os mais frequentes (23,5%) formados pela tríade: amicacina + vancomicina + piperacilina com tazobactam. Conclusão: A incidência de RAM é maior quando se incorpora ao serviço de farmacovigilância a técnica de monitoramento contínuo dos pacientes hospitalizados e se utiliza a analise de exames laboratoriais como preditores para suspeitas de RAMs potencialmente graves / Introduction: Adverse Drug Reaction (ADR) is any noxious, undesired or unintended response which occurs in the use of normal dosages of drugs for prophylaxis, diagnosis, treatments or for modifying physiologic functions. Nowadays, ADR represents one of the main causes of morbidity and mortality in the health service area. Objective: To analyze the occurrence of adverse reaction to drugs and factors related to orthopedic patients treated with antibiotics. Method: The prospective cohort study was conducted in 273 orthopedic patients hospitalized at the Brazilian Institute of Traumatology and Orthopedics in Rio de Janeiro. The data collection was made during the years 2012 and 2013, using instruments composed by demographic-clinical variables and drug therapies. With the purpose of identifying occurrences of ADRs, during active monitoring, interviews were conducted, medical charts and exams were analyzed. In addition, the occurrence of ADRs considered harmful was analyzed by using a form provided by the Catalan Institute of Pharmacology, Spain. In the study of the data collected, was made use of Mann-Whitney tests, Chi-Squared test, Fishers exact test and logist regression, with p-value 0,05. Results: The occurrence of ADRs was of 41%. This group was composed by individuals with major age rage (43,3, SD 10,9), major time spent hospitalized (72,7; SD 40,9), and quantity of concurrent drugs used (13,2; SD 4,1). Also, the related factors were the number of drugs, the usage of Antimicobacterial agents (OR 2,44, CI 1,394-4,270) and Carbapenemases (OR 2,38; CI 1,167 4,872). During the study, there were identified 466 ADRs, and the majority (67,1%) was classified as low-grade. Additionally, in the group of patients with harm adverse reactions, it was possible to identify leukopenia (46,6%), acute kidney failure (40%) and drug-induced hepatitis (26,6%). The antibiotics were the main drugs suspected to be the cause of potentially harmful ADRs (76,4%), being the most frequent (23,5%) formed by the triad: amikacin + vancomycin + piperacillin-tazobactam. Conclusion: The occurrence of ADRs is higher when the practice of continuous monitoring of hospitalized patients is incorporated to the pharmacovigilance service, and the analyzes of lab exams are used as predictors for the suspicion of potentially harmful ADRs