Pharmacologic adjuncts to conventional periodontal therapy
Definitions & Key takeaways
Periodontal disease refers to a group of inflammatory conditions that affect the tissues around the teeth, such as gingivitis and periodontitis. The conventional treatment of periodontal disease is based on mechanical therapy like using curettes to scale and root plane or surgical procedures. However, not all patients respond well to conventional therapy, so pharmacological agents can be useful adjuncts in these cases.
Common pharmacologic adjuncts used in periodontal therapy include: Antibiotics: These are used to reduce the bacterial load in the periodontal pocket and to help control infection. Commonly used antibiotics include tetracyclines, metronidazole, and amoxicillin. Non-steroidal anti-inflammatory drugs (NSAIDs): These are used to reduce inflammation and pain associated with periodontal disease. Examples of NSAIDs include ibuprofen and naproxen. Chlorhexidine: This is an antiseptic mouthwash that helps to control the growth of bacteria in the mouth, particularly in the periodontal pockets. Host modulation therapy: aims to decrease or resolve the immune-mediated destruction of the periodontium.
Periodontal disease refers to a group of inflammatory conditions that affect the tissues around the teeth. The mildest form of periodontal disease is gingivitis and, if left untreated, gingivitis can progress to periodontitis.
Now, the primary goal of periodontal therapy is to save the natural dentition and periodontium but also to prevent recurrence of the periodontal disease.
The conventional treatment is based on mechanical therapy like using curettes to scale and root plane or surgical procedures.
However, not all patients respond well to conventional therapy, so pharmacological agents can be a useful adjunct in these cases.
Now, based on the type of delivery, medications used in the treatment of periodontitis can be subdivided into topical, local, and systemic medications.
The most common topically-delivered medications are antiplaque agents, which are usually delivered in the form of mouthwashes.
Based on their antimicrobial and antiplaque effect, these agents are subdivided into three generations. First-generation agents include fluoride, oxygenating agents, phenolic compounds, quaternary ammonium compounds among other antimicrobials.
Second-generation agents like chlorhexidine gluconate have prolonged antibacterial activity. Finally, we have third-generation agents that interfere with the ability of the bacteria to attach to the teeth.
The main representative of this group is delmopinol hydrochloride. Now, switching gears and moving on to local delivery medications, which can be subdivided into oral irrigation and local sustained delivery.
An oral irrigator is a device that directs a stream of pressurized water or solutions along the gingival margin and between teeth.
On the other hand, in subgingival irrigation, a tip is delicately placed beneath the gingival margin so irrigation penetrates deep into periodontal pockets and targets the bacteria in around 70% of the subgingival region.
Subgingival antimicrobial irrigants include sodium hypochlorite and povidone-iodine. Sodium hypochlorite in a 0.1% solution serves as a broad spectrum oxidizing substance with rapid bactericidal action.
It can be applied by the dentist or at home 2-3 times per week using an irrigation device. The main disadvantages of sodium hypochlorite include unpleasant taste and possible irritation of the oropharyngeal mucosa.
Another-broad spectrum antiseptic is a 10%-solution of povidone-iodine. This is a relatively non-toxic and non-irritating solution that is delivered by dental professionals, who use a syringe to deliver the povidone-iodine solution into subgingival spaces continuously for 5 minutes.
The main disadvantages include unpleasant taste, staining of teeth, and allergic reactions in some patients. Moreover, povidone-iodine is contraindicated in pregnant and nursing women and individuals with thyroid dysfunction and povidone-iodine allergies.
The next delivery method is local sustained release, which is typically used for locally-delivered antimicrobials. These medications cause a slight improvement in clinical attachment levels, probing depths, and gingival bleeding so they are usually used as an adjunct to scaling and root planing.
Locally-delivered products include PerioChip, Atridox, and Arestin. PerioChip is a small biodegradable chip in the form of a thin wafer that contains 2.5 milligrams of chlorhexidine gluconate.
Since chlorhexidine gluconate is an antiseptic agent, it’s not associated with bacterial resistance. Once applied into the periodontal pocket, the chip starts to biodegrade and within the first 24 hours it releases approximately 40% of chlorhexidine gluconate.
Over the next 7 to 10 days, PerioChip linearly releases the rest of chlorhexidine gluconate, maintaining the concentration in the gingival crevicular fluid above the minimum inhibitory concentration of 90% of the oral bacteria, or MIC90.
This linear release is also referred to as the first-order release. The next one is Atridox, which is a product composed of a two syringe system.
Syringe A contains biodegradable gel; while syringe B contains doxycycline hyclate, which is a broad-spectrum antibiotic with a bacteriostatic effect.
When prepared, Atridox is administered via a syringe into a subgingival region. Once administered, periodontal pockets that contain doxycycline should be covered with a periodontal dressing or dental adhesive..
Just like Periochip, Atridox is first-order release, but the MIC90 is lower. Moving on to Arestin.
This is a locally-delivered antibiotic based on a biodegradable microsphere technology, which is generally easy to use because it does not require reconstitution or refrigeration.
In Arestin, minocycline hydrochloride is incorporated into a bioadhesive and bioabsorbable polymer called PGLA. Just like Atridox, Arestin is administered via syringe into subgingival spaces but the MIC90 is even lower.
Finally, we have systemic delivery of medications, which includes systemic administration of antibiotics and host modulation therapy.
Systemic antibiotics can be used in individuals with aggressive forms of periodontitis, refractory forms of periodontitis, acute infections, diabetes, and dental implants.
However, it’s important to note that systemic antibiotics are not indicated for most periodontitis cases since overuse could increase bacterial resistance.
Now, to treat aggressive and refractory forms of periodontal disease, first take a culture from the most active sites for attachment loss and determine which antibiotics or combination of antibiotics will be most effective.
Next, mechanical therapy will be used to disrupt the biofilm and then antibiotic therapy will begin. Commonly used antibiotics include combinations of metronidazole and amoxicillin or metronidazole and ciprofloxacin.
Metronidazole, ciprofloxacin and doxycycline have also been used as a single antibiotic. On the other hand, individuals with periodontal abscess can be treated with antibiotics if the clinician feels there are signs of systemic involvement like fever, malaise, or lymphadenopathy; or if the pocket is too tortuous to establish adequate drainage mechanically.
We can also use host modulation therapy to help decrease or resolve the immune-mediated destruction of the periodontium.
This destruction occurs because dysbiotic bacteria trigger the host’s immune system to produce enzymes called matrix metalloproteinases among other molecules, which can damage the supporting structures in the periodontium.
Host modulation therapy is generally reserved for individuals who don’t respond well to conventional mechanical therapy.
The only agent approved to treat periodontitis is sub antimicrobial dose of doxycycline hyclate, the brand name is Periostat.
It has an anti-collagenase and anti-matrix metalloproteinase activity in the gingival crevicular fluid which decreases the breakdown of supporting structures in the periodontium.
Individuals with chronic periodontitis should take 20 milligrams, or one capsule of Periostat, two times a day. Periostat can be used as an adjunct to scaling and root planing because this combination is more effective than scaling and root planing alone.
Other medications include nonsteroidal anti-inflammatory drugs, statins and bisphosphonates, may also act as host modulating agents if the patient is already taking them for other health issues, however, they are not prescribed specifically to treat periodontitis.
Nonsteroidal anti-inflammatory drugs include medications such as indomethacin, flurbiprofen, ibuprofen, naproxen, and ketoprofen.
These medications decrease the production of inflammatory mediators called prostaglandins, thereby reducing gingival inflammation and bleeding.
People taking these medications to lower their serum lipid levels might also benefit periodontally. Finally, we have bisphosphonates, such as alendronate.
Some studies have shown that these medications may decrease alveolar bone loss. So people taking bisphosphonates for osteoporosis may also benefit periodontally.
Most of the other candidate drugs for host modulation therapy are still in the experimental phase. Despite the potential of targeted approaches to inhibit periodontal destruction, a greater challenge is to clinically validate candidate drugs in terms of their risks and benefits, as adjunctive therapies for the treatment of periodontitis.
##Summary Alright, as a quick recap. The primary goal of periodontal therapy is to preserve the natural dentition and periodontium but also to prevent recurrence of the periodontal disease.
Periodontitis is generally treated using a mechanical approach which involves scaling and planing the teeth, re-evaluating the result, possible follow-up periodontal surgery, and a periodontal maintenance program.
Pharmacologic agents can be used as adjuncts to the conventional mechanical approach. Based on the type of delivery, medications used in the treatment of periodontitis can be subdivided into topical, local, and systemic medications.
The most common topically-delivered medications are antiplaque agents, which are usually delivered in the form of mouthwashes.
Based on their antimicrobial and antiplaque effects, these agents are subdivided into three generations. The most effective one is the second generation agents like chlorhexidine gluconate.
Next, we have local delivery of medications, which includes oral irrigation and local sustained release. Oral irrigation is further subdivided into supragingival irrigation, which disrupts dental biofilm along the gingival margin; and subgingival irrigation, which reduces the pathogenicity of the polymicrobial biofilm in the subgingival environment.
Common antimicrobial irrigants include sodium hypochlorite and povidone-iodine. On the flip side, local release products include PerioChip with an active ingredient chlorhexidine gluconate; Atridox, which contains doxycycline hyclate; and Arestin, with an active ingredient minocycline hydrochloride.
Finally, systemic delivery covers the systemic use of antibiotics and host modulation therapy. Remember that systemic antibiotic therapy is generally not indicated except in certain cases like if there’s aggressive or refractory periodontitis.
Finally, host modulation therapy aims to decrease or resolve the immune-mediated destruction of the periodontium. Sub antimicrobial dose of doxycycline hyclate has been approved to treat periodontitis mainly due to its anti collagenase and anti-matrix metalloproteinase activity and it has little effect on the periodontal flora.
Medications like NSAIDs, statins and bisphosphonate can provide periodontal benefits but they are not prescribed to treat periodontitis.
immune-mediated destruction of the periodontium subantimicrobial dose of doxycycline hyclate has been approved to treat periodontitis mainly due to its anti collagenase and anti Matrix metalloproteinase activity and it has little effect on the periodontal microbiota medications like NSAIDs statins and bisphosphonates can provide periodontal benefits that they are not
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