Periodontology Pharmacology

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Periodontology Pharmacology

• Weinberg, chapter 11

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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
   systems
3. Understand how to select the optimum intervention
   for individual clients
4. Research on the internet specific types of
   controlled release systems
5. Understand the need to stay current regarding use
   and delivery of chemical agents

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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

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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

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Client Considerations

• Site specific or general application
• Client sensitivity
• Appropriate follow-up evaluation
• Response of tissues
• Client compliance
• Discuss with client
• Name of agent method of use
• Anticipated outcomes
• Side effects

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Chlorhexidine

• Available CHX (0.12) products
• ProSol CHX (Dentsply)
• Peridex (PG)
• PerioGard (Colgate)
• OraCleanse (Germiphene)

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Chlorhexidine

• Mechanism of action
• Broad spectrum bactericidal agent
• High substantivity
• Binds to oral tissues
• Released in active form for up to 5 hours
• Ruptures bacterial cell membrane ? releases
  cytoplasm contents
• Reduces adherence capacity of P.g.

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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

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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)

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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

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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

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Chlorhexidine

• Clinical efficacy
• 2 months 8 months following debridement full
  mouth disinfection
• Reduction in spirochetes motile rods
• Some probing depth reduction in deep pockets

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Chlorhexidine

• Re-assessment
• Re-evaluate at 4-6 weeks again at 3 months
• Outcomes met?
• Re-treatment required?
• Discontinue use?

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PerioChip?
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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

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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

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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

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PerioChip?

• Recommended dose
• One PerioChip? into one periodontal pocket
• Not recommended to place more than 2 chips around
  one tooth at one time
• Can be administered once/3 months (PD ? 5 mm)

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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

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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

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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

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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

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Listerine

• 1920s ad
• Current

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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

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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

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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

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Quaternary Ammonium Compounds

• Breath Fresheners

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QAC

• Available products
• Scope (PG)
• Cepacol (J.B. Williams)
• Viadent Oral Rinse Advanced Care (Colgate)
• Oral-B Antiplaque Rinse
• Active ingredient Cetylpyridinium chloride

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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

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QAC

• Side effects
• To be effective, must be used 4 times/day
• With this frequency of use expect
• Burning, staining
• Soft tissue irritation
• Increased calculus formation

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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