Periodontology Pharmacology

Weinberg, chapter 11

Learning Objectives

1. Discuss the rationale for the use of chemical agents in the treatment of periodontal diseases

2. Describe the various types of drug delivery systems3. Understand how to select the optimum intervention

for individual clients4. Research on the internet specific types of

controlled release systems5. Understand the need to stay current regarding use

and delivery of chemical agents

Qualities of the Ideal Chemical Agent

Bacterial specificity Inhibit overgrowth of other organisms Low drug induced resistance Nontoxic to oral tissues High substantivity Limited systemic absorption

Selection of a Chemical Agent

Ideal: determine specific type of pathogen select antimicrobial

Reality: evidence based selection In-office testing: takes little time, improves

selection knowledge improves outcomes Costly to client

Client Considerations

1. Site specific or general application2. Client sensitivity3. Appropriate follow-up evaluation

Response of tissues Client compliance

4. Discuss with client Name of agent & method of use Anticipated outcomes Side effects

Chlorhexidine

Available CHX (0.12%) products: ProSol CHX (Dentsply) Peridex (P&G) PerioGard (Colgate) OraCleanse (Germiphene)

Chlorhexidine

Mechanism of action: Broad spectrum bactericidal agent High substantivity

Binds to oral tissuesReleased in active form for up to 5 hours

Ruptures bacterial cell membrane releases cytoplasm contents

Reduces adherence capacity of P.g.

Chlorhexidine

Not all clients exhibit undesirable side effects Side effects may include:

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

If client rinses with water right after rinsing with CHX Mucosal desquamation

Chlorhexidine

Side effects: Interacts with positively charged detergents

30 min. between brushing & rinsing with CHX Japanese race prone to CHX allergies 30 min. time lapse between rinsing with CHX & rinsing

with fluoride (SnF) High alcohol content (11.6%)

Dehydrates mucosa & may intensify pain Increased risk of oropharyngeal cancer (possible)

Chlorhexidine

Use of CHX: Inhibits dental plaque & gingivitis Full mouth disinfection Oral mucositis Site specific professional irrigation

Furcations, deep pockets Home irrigation or rinsing Post-periodontal surgery Some therapeutic value in treating candida infections

Chlorhexidine

Instructions for use: Rinsing:

15 ml for 30s bid Short term therapy (1-2 weeks up to 3 months))

Irrigation: Professional: 0.12% At-home: 0.06% daily

Pre-procedural rinse 10 ml for 60s

Chlorhexidine

Clinical efficacy: 2 months & 8 months following debridement &

full mouth disinfectionReduction in spirochetes & motile rods

Some probing depth reduction in deep pockets

Chlorhexidine

Re-assessment: Re-evaluate at 4-6 weeks & again at 3 months

Outcomes met?Re-treatment required?Discontinue use?

PerioChip

PerioChip

Description: Rectangular chip, supplied in boxes of 10 chips Contains 2.5 mg Chlorhexidine D-gluconate Biodegradable matrix of hydrolyzed gelatin Store in refrigerator until use 2 year shelf life

PerioChip

Mechanism of action: Bactericidal antiseptic agent Binds with tissue – no need for surgical dressing Chip gradually biodegrades releasing CHX Sustained release over period of 7-10 days GCF concentrations vary among clients

Peaks at (2-4) hours after insertion Peaks again at approx. 72 hours Concentrations gradually decline over 7-10 day period

PerioChip

Indications: Adjunctive therapy to debridement Clients with adult periodontitis

Bleeding/nonbleeding pockets 5 mm Where maintenance is preferred choice for care

Surgical care is contraindicated

PerioChip

Recommended dose:One PerioChip into one periodontal pocketNot recommended to place more than 2 chips around

one tooth at one timeCan be administered once/3 months (PD 5 mm)

PerioChip

Adverse reactions: Approx. 40% of teeth associated with chip

insertion experience tooth sensitivity – dissipates as chip dissolves

Slight pressure for 24 hours Mild-moderate swelling, gingival sensitivity Likelihood of reaction increases with repeated

administration

PerioChip

Client information: Brush as usual Avoid flossing around teeth with inserted PerioChip

for 10 days Contact dental office if:

Chip dislodges Pain intensifies

No bacterial resistance (studies conducted over 2 year period)

No tooth staining or altered taste perception

PerioChip

Administration: Keep chip refrigerated until ready to use Thorough debridement of area to be treated Irrigate area to flush out debris Dry area Grasp chip with non-serrated cotton pliers Entire chip must be submerged – use probe to

maneuver chip to pocket base

PerioChip

Clinical efficacy: Depends on study read Expected outcomes:

Reduction in PD depths, increased CAL, less bleeding Greater PD reduction when chip used in

conjunction with debridement Reductions in probing depths reported anywhere

from 1.0 mm – 2.0 mm or greater

Listerine

1920s ad

Current

Essential Oils

Available products: Listerine (Warner & Lambert)

Mechanism of action: Formulation includes:

Thymol & eucalyptol with menthol & methylsalicylate Low substantivity Disrupts bacterial cell wall & inhibits bacterial enzyme

production

Essential Oils

Side effects: Alcohol levels high (original formula: 26.9%;

Cool Mint: 21.6%)Carcinogenic potential (insufficient evidence to link

oral cancers with mouthrinses containing alcohol) Slight extrinsic staining Drying effects Temporary burning sensation, unpleasant taste

Essential Oils

Use of Essential Oil mouthrinse: Anti-plaque & anti-gingivitis 20 ml full strength for 30s bid More frequent use may lead to desquamation of oral

tissues Clinical efficacy:

About 50% as effective as CHX Plaque reductions range from 20-40% Gingivitis reductions range from 25-35%

Quaternary Ammonium Compounds

Breath Fresheners

QAC

Available products: Scope (P&G) Cepacol (J.B. Williams) Viadent Oral Rinse Advanced Care (Colgate) Oral-B Antiplaque Rinse

Active ingredient: Cetylpyridinium chloride

QAC

Mechanism of action: Increased bacterial cell wall permeability

(favours lysis) Alatered cell wall metabolism Decreased ability for bacterial to adhere to oral

surfaces Low substantivity (about 3 hours)

Marketed more as breath freshener

QAC

Side effects: To be effective, must be used 4+ times/day With this frequency of use expect:

Burning, stainingSoft tissue irritation Increased calculus formation

QAC

Use of products: Anti-plaque (up to 14%) Anti-gingivitis (up to 24%) Short term studies only Activity altered by abrasives, flavoring agents

Rinse wait 30 minutes brush