Periodontology Pharmacology Weinberg, chapter 11

Learning Objectives Discuss the rationale for the use of chemical agents in the treatment of periodontal diseases Describe the various types of drug delivery systems Understand how to select the optimum intervention for individual clients Research on the internet specific types of controlled release systems 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 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

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: Irrigation: 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 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 Where maintenance is preferred choice for care Surgical care is contraindicated

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: Mechanism of action: 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: Clinical efficacy: 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: Active ingredient: Cetylpyridinium chloride 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: Marketed more as breath freshener 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

Periodontal Pharmacology 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 Soft Tissue Management DEN4361