DR - Hayder A. Alwaeli: Jordan University of Science & Technology

Dr.Hayder A.
Alwaeli
Jordan University of Science &
Technology
Periodontal diseases comprise a group of
chronic inflammatory disorders with bacterial
etiology that results in breakdown of the
connective tissue
Safe & intrinsically efficacious
medications can be delivered into
periodontal pockets to suppress
or eradicate the pathogenic
microbiota or modulate the
inflammatory response
Local vs. Systemic Application
of Antimicrobials
 Advantage-Local  Disadvantage-Local
1. More conc. 1. More chair side
2. Fewer side effects 2. More expensive
3. Sustained delivery 3. No effect on bacterial
4. Patients compliance reservoir
Local versus Systemic applications
 Unwanted adverse effects of systemic
antibiotics
 Emergence of bacterial resistant to
systemic antibiotics
 Some of them including TET.s & CHX
pocess an important property which is
substantivity
 For effective periodontal treatment by
antimicrobial agents, there is a need for
a high conc.
Local Application of Antimicrobial
Drug
 The medication must reach the
intended site of action
 Remain at adequate concentration
 Last of sufficient duration of time

 Pharmacological agents applied locally
 Bacteria residing in periodontal pocket
 Soft tissue walls of the pocket
 The exposed cemetum or radicular dentin
(Saglie FR 1991,Saglie etal 1982)
 Not all antimicrobial agents reaches to these

locations
e.g. : mouth rinses,supragingival irrigation (≤ 5mm)
Periodontal Clearance
Substantivity
LOCAL DRUG DELIVERY DEVICES
( L.D.D.D. )
L.D.D.D. : consists of a drug reservoir and a limiting element
that controls the rate of medicament release
 The goal is to maintain effective conc. of chemotherapeutic agents at the site
of action for long periods, despite drug loss from G.C.F. clearance
L.D.D.D.
( according to the duration of medicament release )
Sustained release Controlled delivery

devices devices
( Less than 24 hrs ) ( Exceeds one day )
These are generally the delivery systems with regulatory
approval by the ( FDA ) or the regulatory bodies of the
European Union
At present 5 products are commercially available
1. Tetracycline fibers (Actisite, Alza corp., Mountain view, C.A.)
2. Metronidazole gel ( Elyzol, Dumex, Copenhagen, Denmark )
3. Minocycline gel (Arestin,Lederle,U.K.)
4. Chlorhexidine chip (Periochip)
5. Doxycycline hyclate in a resorbable polymer (Atridox, Collines,
Co.)
Role of Local Delivery of
Antimicrobials
 Localized sites of inflammation associated
with PD> 5mm that did not respond to SRP
and are not eligible for surgery
 Localized sites of inflammation associated

with recurrence or persistence of PD > 5mm
in maintenance patients
 Surgery is unpredictable or undesirable
 Used as an adjunct to mechanical therapy

and not as a substitute

 Non – resorbable cylindrical D.D.D. made of

 a biologically inert,plastic copolymer .
 loaded with 25% Tet. HCL powder.
 The fiber is applied to completely fill the

pocket
 Maintained in situ with a cyanoacrylate

adhesive for 7 –10 days, conc. excesses
1,300 ug/ml Goodson et al 1991,Tonnetti et al 1994
Actisite Fiber
 10% doxycycline hyclate gel
 Mixed and Injected into the site
 Continued release for 7 days
 Biodegradable
 Needs training but relatively

simple to use
 Before Atridox
 Isodent placed
 After Atridox
 Before
 Is a bioabsorbable sustained delivery
system consisting of :
 ( 2% ) Minocycline HCL in a matrix of Hydroxyethyl
cellulose
 Amino alkyl methacrylate
 Tryasitian & glycerin Magnesium chloride is added to modify
the drug release properties
 Bacteriostatic antibiotic , no data

regarding the period of it’s reservoir
 Clinical use:
 Periodontitis with pockets >= 5 mm
 How supplied:
 Box containing 2 trays each containing 12 cartridges
 Cartridge contains 1 mg of minocycline (semisynthetic

tetracycline derivative) microencapsulated in Poly dry powder
 Cartridge inserted into a cartridge handle

 Mechanism of action:
 Broad spectrum
 Bacteriostatic
 G.C.F levels maintained at high levels for at least 14 days
Chlorhexidine (Periochip 2.5
mg )
 2.5 mg of Chlorhexidine in
biodegradable chip
 Used only in pockets > 5 mm
 Insertion could be challenging, it

should be gently pushed into
pocket
Periochip dimensions
Chlorhexidine
 3 Forms: digluconate , acetate and hydrochloride
salts.the first two are water-soluble
 Palque inhibition was first investigated in 1969 by
Schroeder
 The definitive study was by Loe& Schiott 1970:
showed that rinsing with 10ml of 0.2%(20mg dose)
twice daily in absence of normal tooth cleaning
inhibited plaque regrowth and development of gingivitis
Chlorhexidine/ Characteristics
 Bisguinide antiseptic
 Strong base & dicationic at pH above 3.5 extremely
interactive with anions
 Minimally absorbed through skin or mucosano systemic
toxicity
 Can cause neurosensory deafness if introduced into the
middle ear
Chlorhexidine/ Characteristics
 Has a broad antimicrobial action,G+ve & against

some fungai & yeast as candida ,and against
some viruses including HBV & HIV
 No reported bacterial resistance with long term

use
Chlorhexidine/ Side effects
 Brown discoloration of teeth ,dorsum of tongue and
restorative materials
 Taste perturbation mainly salt tastebland taste
 Oral mucosa erosion
 Unilateral or bilateral parotid swelling???
 Enhanced supragingival calculus formation?
 Has a bitter taste

Chlorhexidine/ Side effects
Mechanisms of staining:
Chlorhexidine /mechanism of
action
Chlorhexidine/Forms
 Mouthwashes: 0.2,0.1 and 0.12%
use 15ml 0.12% equal to 10 ml 0.2%
 Gel: must be delivered to all tooth
surfaces
 Sprays: for physically or mentally
handicapped.
 Toothpaste :difficult to formulate
 Varnish: for root caries prevention

Chlorhexidine/ uses
 Adjunct to OH and professional prophylaxis
 Postoral surgery
 Jaw fixation
 Mentally and physically handicapped
 Medically compromised predisposed to oral infections
 High-risk caries
 Recurrent oral ulcerations
 orthodontics appliance
 Denture stomatitis
 Immediate preoperative rinsing
 Subgingival irrigation
Chlorhexidine/conclusions
 Chlorhexidine to date is the proven most effective
antiplaque agent for which commercial products are
available to the public
 Chlorhexidine is free from systemic toxicity in oral use, and

microbial resistance and supra-infection do not occur
 Local side effects are reported which are mainly cosmetic

problems
 The antiplaque action of chlorhexidine appears dependent

on prolonged persistence of antimicrobial action in the
mouth (substantivity)
Chlorhexidine/conclusions
 A number of vehicles for delivering chlorhexidine
are available, but mouthrinses are most commonly
recommended
 Extrinsic dental staining &perturbation of taste are

variably the two side effects of chlorhexidine
mouthrinse usage which limit acceptability to
users and the long-term employment of this
antiseptic in preventive dentistry
Gel OR Conventional toothpaste
Why paste is striped
Benefits of toothpastes
 Caries control
Fluoride is available in a range of concentrations

250-2800 ppm.
 [F]≤ 600ppm → children ≤7years with low caries
incidence.
 [F] =1000ppm → children ≤7 years with high caries
risk
 [F]1000-1500ppm → all individuals 7 years and
above.
 [F]2800ppm→ high risk adults and elderly
 Gingivitis and periodontitis:
Triclosan is the most widely used

antimicrobial
It also has anti-inflammatory properties
&thus could reduce gingival inflammation
independent of its effect on plaque
 Dentine sensitivity:
 Strontium chloride 10%

 Potassium nitrate
 Potassium citrate
 Stannous fluoride
 Anti-tartar
 Soluble pyrophosphate
 Zinc salts
 Triclosan
 Whitening
 The main action is through abrasive removal
of extrinsic stains
Whitening toothpastes
 Abrasives
Macleans whitening, colgate platinum
 Oxidizing agents
Brilliant whitenning system,Rapid white

 Enzymes
Rembrandt original
 Detergents
Aquafresh whitening.
 EDTA
Boots advance white

 Choose a toothpaste that is fluoridated, brush for 2
minutes at least twice daily
 Studies suggested that bacteria regrow on clean

teeth about 4 hours after brushing -> brush and
floss regularly
 The mechanical action and the technique of

brushing are much important than the brand of the
toothpaste
 Current data suggest that L.D.D of antimicrobials
into a periodontal pocket can improve periodontal
health
 Monotherapy with them is questionable , adjunctive
use of L.D.D. may enhance the results in sites that
don’t respond to conventional therapy

 L.D.D.D. should only be used in specific
areas were conventional forms of therapy
may fail to control infection
 So it should not be used routinely in
situations when efficacious results can be
accomplished with SRP

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Dr.Hayder A.

 The medication must reach the

intended site of action

 Remain at adequate concentration

 Last of sufficient duration of time

 Not all antimicrobial agents reaches to these

 The goal is to maintain effective conc. of chemotherapeutic agents at the site

Sustained release Controlled delivery

At present 5 products are commercially available

1. Tetracycline fibers (Actisite, Alza corp., Mountain view, C.A.)

2. Metronidazole gel ( Elyzol, Dumex, Copenhagen, Denmark )

3. Minocycline gel (Arestin,Lederle,U.K.)

4. Chlorhexidine chip (Periochip)

5. Doxycycline hyclate in a resorbable polymer (Atridox, Collines,

 Localized sites of inflammation associated

 Surgery is unpredictable or undesirable

 Used as an adjunct to mechanical therapy

 Non – resorbable cylindrical D.D.D. made of

 loaded with 25% Tet. HCL powder.

 The fiber is applied to completely fill the

 Maintained in situ with a cyanoacrylate

 Mixed and Injected into the site

 Continued release for 7 days

 Needs training but relatively

 Bacteriostatic antibiotic , no data

 Cartridge contains 1 mg of minocycline (semisynthetic

 Cartridge inserted into a cartridge handle

 Used only in pockets > 5 mm

 Insertion could be challenging, it

 Has a broad antimicrobial action,G+ve & against

 No reported bacterial resistance with long term

 Taste perturbation mainly salt tastebland taste

 Oral mucosa erosion

 Unilateral or bilateral parotid swelling???

 Enhanced supragingival calculus formation?

 Has a bitter taste

 Varnish: for root caries prevention

 Chlorhexidine is free from systemic toxicity in oral use, and

 Local side effects are reported which are mainly cosmetic

 The antiplaque action of chlorhexidine appears dependent

 Extrinsic dental staining &perturbation of taste are

Fluoride is available in a range of concentrations

Triclosan is the most widely used

 Strontium chloride 10%

Brilliant whitenning system,Rapid white

Boots advance white

 Studies suggested that bacteria regrow on clean

 The mechanical action and the technique of

into a periodontal pocket can improve periodontal

 Monotherapy with them is questionable , adjunctive

use of L.D.D. may enhance the results in sites that

don’t respond to conventional therapy

areas were conventional forms of therapy

may fail to control infection

 So it should not be used routinely in

situations when efficacious results can be

accomplished with SRP

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