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Pharmacologic adjuncts to conventional periodontal therapy

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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.

The stream of water disrupts the formation of the dental biofilm and decreases gingival inflammation.

Oral irrigation is further subdivided into supragingival and subgingival irrigation.

In supragingival irrigation a tip is placed above the gingival margin.

This makes supragingival irrigation effective in removing bacterial biofilm along the gingival margin.

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.