medicament pdf - د.زكريا

17/06/2013

Medicament used in the treatment

of periodontal disease

Dental plaque

Accumulation of dental plaque induce inflammatory

response in Gingiva that may spread to connective

tissue & bone

Plaque control measures include mechanical &

chemical means

plaque control measures aim inhibition of plaque

formation or reducing at regular intervals amount

of plaque to a level at & below which no

inflammatory disease develops

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In certain types of diseases like ;

advanced chronic periodontitis,

refractory periodontitis ,

aggressive periodontitis &

periodontitis as manifestation of systemic

diseases

ADJUNCTIVE

chemotherapeutic agents are

necessary

Large no.of microorganism responsible for

initiation & progression of periodontal disease

according to non-specific plaque theory

mechanical & chemical plaque controls aim

elimination of entire plaque mass

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Non-specific plaque theory

Periodontal disease results from elaboration of noxious

products by entire

plaque

flora

when few

plaque

are present, noxious products

neutralized by host defense.

Similarly, large amount of

plaque

produce more noxious

products that overcome host defense

• Support this theory
• control of plaque accumulation
• by mechanical debridment
• & Oral hygiene measures
• induce control of disease in spite of
• the direction toward specific plaque theory

Specific plaque theory

Only certain plaque is pathogenic & its pathogenicity

depends on presence or increase in specific microorganism

So if plaque contains pathogenic

microorganism the periodontal disease will

result & if not no periodontal disease occur

That is why certain patients with plaque &

gingivitis not develop to periodontitis

(contained Gingivitis)

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Specific plaque theory

Also patients with periodontitis show

site specificity in pattern of disease as some

sites were disease free while others show

advanced disease in the presence of uniform

host response

Because of increase ability to isolate periodontal

microorganism

(improved sampling of subgingival plaque &

culturing media)

Specific plaque theory

More acceptance of such hypothesis especially

after recognition of A.a. as pathogen in

aggressive periodontitis

Also they have detected

One or few bacteria within plaque mass

constitute the etiological factors

antimicrobial drugs should have a potential to

eliminate pathogenic bacteria only

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Specific plaque theory

Unfortunately

only few bacteria have been identified as pathogen & satisfy

kochs postulate

among more than 600 species of normal inhabitants of oral

cavity

Good response of some disease

to unique spectrum antimicrobial agent

support such theory

Kochs postulate

Classic criteria by which microorganism can be

judged to be a causative agent in human

infections

Causative agent must ;

1- Be routinely isolated
2- Be grown in pure culture
3- produce similar disease when inoculated into
susceptible laboratory animals
4- Be recovered from lesions in a diseased
animal

Ex; S.mutans in dental caries

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In periodontal disease the problems

are ;

1-inability to culture all organisms associated

with disease (as many oral spirochetes)

2-defficulty inherent in defining & culturing sites

of active disease

3-lack of good animal model system for studying

periodontitis

So SIGMUND

criteria;

• Periodontal microorganism must;

1- be associated with disease, increase in no.at disease site
2- be eliminated or decrease in sites with disease

resolution with treatment

3- demonstrate a host response (cellular & humoral)
4- capable of causing disease in experimental animal

models

5- demonstrate virulence factors responsible for enabling

microorganism to

invade, evade & destruct

For instance:

A.a.& porphyromonas gingivalis

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Antibacterial agent not used routinely for

treatment of periodontal diseases ?

Because periodontal disease considers as

an opportunistic infection not classic

infection

Opportunistic infection

develops usually when organism that already

present in the body allow to multiply & proliferate

when alteration in host resistance happen or

presence of favorable environment as;

favorable environment

Q.& Q. alteration of supragingival plaque

2- calcification
3- faulty dentistry
4- hormonal changes with resultant

gingival enlargement

So Antibacterial agents induce limited & transient

suppression of organisms , regrowth of residual

organisms in unchanged environment will occur

So the treatment directs to changing the

environment rather than giving antibiotic

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•

Complete elimination by chemical &
mechanical means

•

Reduction below certain threshold levels at
which health is maintained

Roll of plaque control measures in prevention of gingivitis & its

conversion to periodontitis

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or
• Alteration of microbial composition by introduction of

non-virulent antagonist to subgingival pathogen thereby
replace virulent strain

• Prevent adhesion of bacteria to tooth surface through a

change in its chemistry ( interference with pellicle
formation & initial adherence to tooth surface)

Roll of plaque control measures in prevention of gingivitis &

its conversion to periodontitis

. The action of the chemicals could

fit into four categories:

Antimicrobial

Antiadhesive Antipathogenic.

Plaque removal

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At present most antiplaque agents are antimicrobial &

prevent the bacterial proliferation phase of plaque

development

plaque formation could be controlled by antiadhesive or

plaque removal agents but these are not as yet available or

safe for oral use

alteration of bacterial plaque pathogenecity through

chemical agents or bacterial modification would require a

greater understanding of the bacterial etiology of gingivitis

Antibacterial agents

they are grouped according to

substantivity

(contact time that connect a substance & a substrate in a given

medium)

Weak substantivity (1

generation ) like ;

certain AB, phenolic compound, oxidizing agent ,fluoride,

plant alkaloids

High substantivity (2

generation ) like chx

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Chlorhexidine digluconate (chx)

Mouthrinsing

with 10ml of 0.2% or 0.12% solution of

chx twice daily produce a plaque reduction of 45-

61% & can safely be used for extended period of

time with no reduction of bacteria sensitivity to chx

Substantivity & mechanism of action

Chx adsorbs to surface of oral tissue including teeth & slowly

released in active form ,about 30% of 10ml will bind &
70% will be spat

Cationic chx molecule bind to anionic component like free

sulfates, carboxyl & phosphate groups of pellicle, thereby
reducing adsorption of protein to tooth required for
formation of plaque

Coating salivary bacteria with chx

molecules also alter mechanism of

adsorption to tooth

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Chx molecules bound to salivary

proteins will be released in active

form in 8-12h with low conc.of chx

can still be recovered after 24h

Chx can eliminate already present

plaque

after 6day of its use by

degradation of glycoprotein

Chx has high affinity to cell wall of bacteria

that lead to its death by;

Attack cell wall & change surface structure

that lead to loss of osmotic equilibrium

later on the cytoplasmic membrane is

extruded with vesicle formation &

Cytoplasmic precipitate that

Inhibit repair of cell wall

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Side effects

1- formation of extrinsic yellow-brown stain (vary from

individual to other & depend on conc.)

2- desquamation & painful mucosal lesions (associated

with high conc.chx)

3- impairment of salty taste perception (transient)
4- ascending parotitis (rare)
5- disturbance of wound healing (associated with high

conc.chx)

6- Enhanced supragingival calculus formation

This effect may be due to the precipitation of salivary

proteins on to the tooth surface , thereby increasing pellicle
thickness and/or precipitation of inorganic salts on to the
pellicle layer
.

Certainly pellicle forming under the influence

of chlorhexidine shows an early and highly

calcified structure

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Metabolism & toxicology

Primary route of excresion is through

feaces

Low toxicity as its poorly absorb from GIT

Has not been associated with terratogenic

alteration

{Safe in pregnancy}

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Clinical applications

Mouth rinses;

2 daily rinses for 30-45 S. with 10ml of 0.2% chx

& advise subject

no water rinsing, eating or drinking for 1/2h

following rinsing

rinsing should be done 1/2h after brushing ?

Irrigators

400ml of 0.02% once daily as adjunctive to

mechanical plaque control

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Gels 1%

apply for 5min once or twice daily on tray or stint

effective in denture stomatitis & oral candidiasis &
for handicapped

Also once daily for 30min to prevent recurrence of

disease following periodontal treatment in patients
lack dexterity

3 daily application of 1% gel

for several weeks reduce severity
& duration of aphthus ulceration

Professional irrigation

by using syringe with blunt needle to enhance

result obtained with S & RP each recall visit

Its effect is controversy

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Chlorhexidine is more effective as a

preventive

rather than a therapeutic agent and

therefore must

be of questionable value as a subgingival

adjunct in

the treatment of periodontitis

Chx dihydrochloride powder used under periodontal dressing

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Chlorhexidine gluconate in a gelatin chip

Several attempts have been made to develop local

delivery devices for

the subgingival application of

antiseptic, rather than antibiotic agents.

Acrylic strips and ethyl-cellulose compounds

have been tested for this purpose

PerioChip

a degradable gelatin chip containing 2.5 mg chlorhexidine,

isthe most extensively tested delivery device of this category

Conc.in Gingival fluid greater than 100ng /ml for at least 7d.

Because the chip biodegrades in 7-10 d.,a 2

appointment

for removal is not needed

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Other vehicle for delivery include;

1. Toothpaste
2. Spray
3. Chewing gum
4. varnish

Indications

1- jaw #
2- orthodontic therapy
3- handicapped pt.
4- elderly pt.
5- leukemic pt.to Mucositis following

chemotherapy

6- adjunctive treatment following periodontal

surgery (1-4w)

7- to augment plaque control during phase 1 therapy
8- pt.with recurrent problems
9- Mucositis following irradiation

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H2P2

Oxidizing agent induce 28% reduction as it consider O2

liberating agent that affect growth of anaerobic bacteria

3-10% solution for topical application used to clean wound &

as a rinsing solution for

Periodontal pocket & initial therapy for NUG

Side effect;

Tissue damage with long term use emphysema if applied

under pressure

hairy tongue

Enzymes

Mucinase

incorporated to dentifrice to inhibit calculus

formation

Urea

induce 30% calculus inhibition

They act to delay plaque mineralization ,keeping

deposits in an amorphous non-hardened state to

aid their removal with tooth brushing & flossing

Fluoride

Low conc.have antimicrobial activity mainly stannous

fluoride than sodium fluoride( bactericidal effect)

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Essential oil mouthrinse & phenolic

compound)

Include broad class of chemicals that used as

antiseptic & disinfectants

Thymol is principle antibacterial component of

commercial preparation

Eucalyptol,

menthol,

methyl salicylate,

Triclosan

Essential oil mouthrinse & phenolic

compound)

Listerine retard accumulation of plaque &

severity of gingivitis

Twice daily rinse for 2w induce plaque reduction

range from

19.5-51%

Side effect ; Initial burning sensation & bitter

taste but acclimatization occurs in few days

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Quaternary ammonium compounds

Benzylconium chloride and, more particularly

cetylpyridinium chloride are the most studied of this

family of antiseptics. Cetylpyridinium chloride is used

in a wide variety of antiseptic mouthrinse products

usually at a concentration of 0.05%.induce 28%

plaque reduction

Side effect; tooth staining

Herbal extract

Sanguinarine
inhibit bacterial adherance & induce 38% reduction in plaque

formation

Twice daily rinse with 0.03% conc.

Recently its increase the likelihood of oral precancerous

lesions almost ten fold even after cessation of mouthwash
use

Myrtus communis (

(

اس

extract from its leaves has antibacterial activity

due to presence of polyphenol

Qureucus infectori

(

عفص

)

antiplaque activity due to presence of tannic acid

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Other antiseptics

A number of antiseptics/antimicrobial agents have been
studied for plaque inhibition. Most have been found to have
little or no effect in vivo; a few have been formulated in
mouthrinse products including

povidone iodine and

hexetidine

Povidone iodine 1%

has a substantivity of only 60 minute  lacks appreciable
plaque inhibitory activity  or action in acute infections such
as acute ulcerative gingivitis , for which it is  recommended.

Povidone iodine is largely without side effects

but as a rinse has potential to affect thyroid function

adversely

Hexetidine 0.1%

saturated pyrimidine, was shown to have limited

plaque inhibitory action and no evidence for anti-
plaque activity when used as an adjunct for oral
hygiene The action of hexetidine against plaque
appears enhanced by zinc salts

side tooth staining and mucosal erosion, although

effects for hexetidine uncommon

Nevertheless, mucosal erosion is markedly

increased in incidence if the concentration is raised
to 0.14%

A mouthrinse product containing 0.1% hexetidine

is available in some European countries