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 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

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 application 2. Client sensitivity 3. Appropriate follow-up evaluation

Response of tissues Client compliance Name of agent & method of use Anticipated outcomes Side effects

4. Discuss with client

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 tissues Released 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)) Professional: 0.12% At-home: 0.06% daily

Irrigation:

Pre-procedural rinse

10 ml for 60s

Chlorhexidine
Clinical efficacy:

2 months & 8 months following debridement & full mouth disinfection

Reduction 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 Surgical care is contraindicated

Where maintenance is preferred choice for care

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)

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) Formulation includes:

Mechanism of action:

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

Clinical efficacy:

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, staining Soft 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