Chemical Periodontal Therapy

CHEMICAL PERIODONTAL

THERAPY

Chemical Periodontal Therapy

Antimicrobial agents;- Antiseptics- Antibiotics

Miscellaneous agents;- Matrix protein- Growth factor- Hydrogen peroxide

Can be used: topically, locally applied & systemically

Any antimicrobial use is ADJUCT to mechanical therapy.

Antimicrobial used in periodontal therapy can be divided in 2 groups:

- Directed against supra-gingival plaque development

- Directed against sub-gingival bacteria


Periodontitis can be classified by:

• Disease activity (chronic/aggressive)• Cause (specific bacterial, fungal / viral infection)• Site (localized or generalized)• Extent (size & morphology defects)• Type of associated gingivitis (chronic/necrotizing)• Type of patient (child, adolescent, adult/ compromised)

Non-specific plaque theory (reduction of bacterial load)

Specific plaque theory (specific plaque therapy)


ANTIBIOTICS

1. Use of antibiotics (systemically / local application) mainly directed against specific bacteria & sub-gingival plaque to target identified periodontal pathogens. Eg. In ANUG & localized aggressive periodontitis.

2. Antibiotics is directed against specific microorganisms, eg. Aa in specific plaque hypothesis in ANUG/P & aggressive periodontitis.

3. While mechanical removal of plaque aimed at reduction of bacterial load for non-specific plaque theory.


ANTIBIOTICS

4. If unresponsive pockets (after reassessment therapy done & no response to therapy), chlorhexidine in slow release of polymer can be used locally, advantage of that, agents can be sustained release within the pocket. Locally applied antibiotics also can be used in this situation.

5. Used of antibiotics in periodontal abscess usually not necessary if the abscess only localized unless there are signs of spread of infection to systemic area / sign of cellulitis/ lymphadenopathy.


ANTIBIOTICS

6. Post surgical rinsing with chlorhexidine mouthwash mainly due to inability to mechanically removed plaque because discomfort.

7. Post surgical systemic antibiotic prescription may not indicated, unless complex surgical procedures been carried out (post-implant surgery) / patient is medically compromised.


ANTIBIOTICS

8. Indication of use of antimicrobial agents to patient with lack of manual dexterity or with patients with mental disability is clear.

9. Patient wearing orthodontics appliances cannot used chlorhexidine mouthwash for a long term due to tooth & tongue staining side effects.


Antibiotics agents:

Local applicationSystemic use


Antibiotics – Local Application

Antibiotics can be in form of:Gel – for topical application onto surface or sub-gingival application.May present in polymer.Also present in the form of biodegradable slow, release gel, hollow or solid fibers.


Antibiotics – Local Application

Examples:a. Elyzol gel - 25% of metronidazoleb. Dentomycin gel - 2% of minocyclinec. Actisite – tetracycline fibers (hollow/solid)d. Periocline - 2% minocyclinee. Atridox - 42.5 mg doxycyclinef. Arestin - 1 mg minocycline


Antibiotics – Systemic Uses

• In the form of liquid, tablets or capsules –suitable if patients diagnosed with aggressive periodontitis ONLY.

• Must finish antibiotic simultaneously with the therapy/ root debridement.


Antibiotics – Systemic Uses (Aggressive Periodontitis )

Amoxicillin in combination with metronidazole (if allergic to penicillin give clindamycin);

- 250 mg amoxicillin & 200 mg metronidazole tds for 4 to 7 days.

Tetracycline

- 250 mg tetracycline for 14 days- Doxycycline 100 mg once a day for 14 days (double dose for first

day because half of it will bind to plasma & another half will be in blood).



• In case of ANUG/P, metronidazole may be needed for 3 – 4 days only.

- 200 mg metronidazole tds for 3 – 4 days.- Analgesic may be prescribed to patient diagnosed with

ANUG/P due to pain.- Since the ANUG/P lesions being very painful to

mechanical plaque control, chlorhexidine may be given.



• For post-surgical systemic antibiotic, metronidazole may be needed for 1 – 7 days.

- 400 mg metronidazole tds for 1 day.- Analgesic may also prescribed.- Chlorhexidine mouthwashes must be given since

the wound may be painful to mechanical plaque removal.



• Periostat® is available as a

- 20 mg doxycycline taken twice daily about an hour before or 2 hours after meals.

- Adjunct to scaling & root planning.- Act as collagenase inhibitor (degrade collagen at

periodontal ligament/gingiva but not to controlled the bacteria) at low concentration.

- Danger to develop bacterial resistance.- Take about a month.


Indications Chlorexidine mouthwash indicated to post-surgical to reduce the bacterial load or to prevent plaque formation at the time when mechanical cleaning difficult due discomfort.

Patient with mental & physically disabilities lack manual dexterity. Examples:

- Parkinson disease- Adjuct to immunocompromised patient (HIV/AIDS)- Cerebral palsy


Indications

In cases like refractory periodontitis (due to smoking), as an adjunct instrumentation, locally applied antimicrobial agents can be used.

Antibiotic prophylactic agents in which the risks of bacterimia & infective endocarditis is high.


Indications

Systemic antibiotics prescribed are directed against specific microorganisms as an adjunct to mechanical instrumentation in aggressive periodontitis & ANUG/P.

The used of systemic antibiotic without cautions can lead to development of bacterial resistance.

Certain individual may suffered from immediate hypersensitivity which can be fatal.


ANTISEPTICS

• Topically (mothwashes)- Oradex – chlorhexidine 0.12%- Listerine® antiseptic mouthwash (phenolic

compound/ essential oil)- Plax® (triclosan)

Typically act supra-gingivaly.


ANTISEPTICS – Mouthwashes

• Quaternary ammonium compound (cetylpyridium chloride)• Hexidine – Bactidol®• Oxygenating agents – hydrogen peroxide• Amine alcohols – Delminol• Povidone iodine natural products – sanguinarines

All these available either as mouthwashes, irrigation, toothpaste, gel/ spray.


ANTISEPTICS

• Locally applied

- Slow release devices (biodegradable polymer, gel, fibers, collagen)

- Applied into periodontal pockets:Perio Chip® (2.5 mg chloroxedine in gelatin matrix) Atrigel® (5% sanguinarine)

Typically act sub-gingivally.


ANTISEPTICS – Chlorhexidine

• Bisguanide compound• Dicationic and strong base• Prolonged action• Concentration – 0.2% or equivalent• The only product to kill bacteria• Not act as anti-adhesive• Only can penetrate into thin plaque not thick /mature (calculus)

plaque.• Can inhibit the plaque formation but cannot eliminate the plaque in

untreated mouth.


Chemical Periodontal Therapy

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