Chapter 52
Periodontal disease is an infectious disease
In a periodontal pocket the bacteria form a highly structured
and complex biofilm. As this process continues, the bacteria
biofilm extends so far subgingivally that the patients cannot
reach it during oral hygiene efforts.
healthy gums
gingivitis
periodontitis
Well, associated with many bacteria, including…
Chemotherapeutic agent is a general term that
refers to the ability of an active chemical substance
to provide a therapeutic clinical benefit.
Chemotherapeutic agent
Clinical benefits can be derived through antimicrobial
actions or an increase in the host,s resistance.
Antimicrobial agents are chemotherapeutic agents that
reduce the amount of microorganisms present either
by specifically targeting certain organisms or by
nonspecifically reducing all.
Currently, an ideal antibiotic for the treatment of
periodontal diseases does not exist. Although oral
bacteria are susceptible to many antibiotics, no single
antibiotics at concentrations achieved in body fluids
inhibits all putative periodontal pathogens.
Indeed, a combination of antibiotics may be necessary
to eliminate all putative pathogens from some
periodontal pockets,these mixed infections can include
a variety of aerobic, micro-aerophilic, and anaerobic
bacteria, both gram positive and negative .
Antibiotics are a form of antimicrobial agents,
naturally occurring semisynthetic or synthetic
produced by or obtained from microorganisms, that
have the capacity to kill other microorganisms or
inhibit their growth generally at low concentrations.
Antibiotics may be specific or cover a broad spectrum.
Dentist Decision
Patient,s clinical status
Nature of the colonizing bacteria
Risks and Benefits
Dentist is responsible for choosing the correct antimicrobial
Allergic
Vomiting
Superinfection
Nausea
Develope resistant bacteria
Gastrointestinal
Interaction,s medications
Cost
Upset stomach
Patient,s willing
Guidelines, for the use of anibiotics in periodontal therapy :
Ι- Clinical diagnosis
ΙΙ- Continous disease active
ΙΙΙ- Selected antibiotics
ΙV- Microbiologic plaque sample
V- Plaque sample at initial examination
Guidelines, for the use of anibiotics in periodontal therapy :
VΙ- Antibiotic value in chronic periodontitis
VΙΙ- Monotherapy antibiotic
ΙΙX- Series of steps
ΙX- Antibiotics as adjuncts to mechanical
therapy
Anti-infective agent
A chemotherapeutic agent that works by
reducing the number of bacteria present.
Antiseptic
A chemical antimicrobial agent applied topically
or subgingivally to mucous membranes,wounds,
or intact dermal surfaces to destroy microorganisms
& inhibit their reproduction or metabolism.
Disinfectants
A subcategory of antiseptics, are antimicrobial
agents that are generally applied to inanimate
surfaces to destroy microorganisms.
Antimicrobial chemotherapy may be used to
support traditional pocket therapy,(scaling
and root planning) and may be employed
systemically or locally (orally) within the
periodontal pocket.
Systemically administered antibiotics they reach
therapeutic levels in periodontium because they are
excreted from the pocket wall into the gingival
crevicular fluid ( GCF ) and/or in the saliva . It is
essential to recognize that periodontal pathogens are
extremely resistant to chemical antimicrobial agents
because of the biofilm effect.
Systemic antimicrobial drug therapy should be
reserved for the small minority of patients,
who in spite of maintaining good plaque control,
have proved unresponsive to conventional
mechanical therapy i.e. those with very aggressive
f o r m s
o f
p e r i o d o n t i t i s .
The clear indications for the use of
s y s t e m i c a n t i m i c ro b i a l d r u g s i n
periodontics include the following:
Treatment of acute periodontal abcesses, acute
necrotizing ulcerative gingivitis or postsurgical
infections. 2- A prophylaxis to prevent systemic
complications for patients who have medical
problems. 3- In conjunction with further
instrumentation to support the host defense system by
suppressing subgingival pathogens that evade the
mechanical debridement process .
Local administration of antibiotics and
antimicrobial agents Vehicles and methods for local
delivery of chemotherapeutic agents:
*Dentifrices. *Mouthwashes. *Chewing gums.
*Home irrigation. *Professional Pocket irrigation.
*Slow-release devices.
Dentifrices / Chewing gums / Mouthwashes Some
of these materials include antibiotics and
antimicrobial agent (medicated).
They are helping in treatment of some cases with
soft tissue inflammation and gingivitis. These are
inefficient delivery systems in periodontitis because
they do not penetrate well into periodontal pockets
and fail to direct drugs into deep affected sites.
Pocket Irrigation. A home irrigation those
devices result in greater access of
medicament to periodontal pockets when
compared with rinsing alone. Different mouth
rinses and saline are used as irrigants.
Nevertheless, these devices may be only
useful in delivering medicaments in cases of
gingivitis with shallow pocket depths.
- Professional Irrigation -This can be done using
syringes, pulsated jet delivery, and coolants during
ultrasonic subgingival scaling. -Irrigants include
chlorhexidine (0.12%), stannus fluoride (1.64%),
Listerine, tetracyclines and other antimicrobial agents.
- Unfortunately, the obtained improvement is confined
to the marginal tissue because an effective
concentration of the antimicrobial agents would not be
established and maintained by this method.
Chlorhexidine gluconate is effective as an antiplaque
rinse to reduce gingivitis but not as a subgingival
irrigant to reduce periodontal pocket it,s an
antiinfective agents.
Tetracyclines
Widely used in the treatment of periodontal diseases.
Frquently used in treating refractory periodontitis .
They have the ability to concentrate in the periodontal
tissues ( 2-10 times in GC than in the serum ) and inhibit
the growth of Aa .
Also exert an anticollagenase effect that can inhibit
tissue destruction & may help in bone regeneration.
Local delivery of antibiotics
The requirements for treating periodontal disease
include a means for targeting an antiinfective
agent to infection sites and sustaining its localized
concentration at effective levels for a sufficient
time while concurrently evoking minimal or no
side effects.
The need to maintain optimal concentration of
antimicrobial agents for use in periodontal pockets has
led to the testing of various sustained and controlled
release delivery systems (slow-release devices). Slowrelease devices -These are vehicles of different materials
that can carry and directly deliver antimicrobial agents
to deep periodontal pockets over an extended period of
time.
The advantages of using locally delivered antibiotics
include the delivery of a high concentration of
antibiotics to a localized area without systemic
involvement, prolonged release over time, minimal risk
of developing bacterial resistance, elimination of
gastrointestinal or other adverse effects related to the
use of systemic antibiotics as well as reduced risk of
noncompliance with systemic antibiotic regimens.
Arestin©
Minocycline
Perio Chip Technical Movie.flv
Advantages of Slow-release devices : This is an
attractive concept which, compared to systemic drug
delivery, and offers the following advantages: *Higher
drug concentrations are achievable in needed sites.
*Drugs unsuitable for systemic administration may be
used. *Dosing is not dependent on patient compliance.
*Resistance at remote body sites may be avoided.
*Superinfection at remote body sites may be avoided.
*Gastrointestinal intolerance is avoided.
Types of slow-release devices A- Ethylene vinyl acetate
(EVA) The EVA system is based on polymer technology,
with tetracycline, EVA fibers have been found to be
flexible and to sustain delivery of tetracycline for up to 9
days. The fibers are placed into periodontal pocket and
maintained there for 10 days by superficial application
of a cy anoacry late ad hesive . B- Ac ry lic and
Ethylecellulose strips These acrylic micro-strips contain
either chlorhexidine or metronidazole.
Disadvantages of the fibers included the length of time
required for placment>10minutes per tooth, and the
need for a second patient appiontment 10 days after
placement for fiber removal, also oral candidiasis in few
patients .
Microspheres MinocyclinD- - These are bioadhesive,
bioresorbable polymer in powder form produced by a
microencapsulation process. Once they are inserted,
they immediately adheres to the periodontal pocket. Crevicular fluid hydrolyzes the polymer causing
water-filled channels to form inside the Microspheres.
These holes provide "escape routes" for the
encapsulated antibiotic for sustained release. C- Gels
Containing 2% minocycline or 25% metronidazol,
these gels allow antibiotics to be syringed into the
p e r i o d o n t a l
p o c k e t .
-The active drug dissolves and diffuses out of the
microspheres through the channels into the
surrounding tissues. -Eventually, the Microspheres
themselves are fragmented through polymer
hydrolysis and completely resorbed.
Methods of application After scaling and root
planning, fibers or strips are placed in the pockets in
a similar manner to placement of retraction cord.
Gels, microspheres or ointments are applied by
special syringes designed for this purpose.
Concluding remarks
1- Antibiotics may be recommended as adjuncts to
conventional forms of therapy (i.e. root planning
or surgery ) not as monotherapy.
2- Routine home irrigation and mouth washes with
or without medicaments reduce gingivitis, but
have no beneficial effect on periodontitis.
3-Professional subgingival irrigation of medicaments
after root planning provides negligible additional
benefit over root planning alone.
4-Antimicrobial containing slow–release devices can
be used to treat periodontal sites that have not
responded well to traditional periodontal therapy .
In this regard bioresobable ones are now being
preferred.