Chemotherapeutic Adjuncts in Periodontal Disease Treatment

• Chemotherapeutic adjuncts are examined for use in periodontal disease treatment.
• This presentation covers adjunct usage, systems, and evidence.

Aim

• Gain knowledge of what a chemotherapeutic adjunct is and when to use it
• Recognise which adjunct to use, whether locally or systemically delivered
• Apply that knowledge appropriately

Intended Learning Outcomes

• Define chemotherapeutic adjunct.
• Become familiar with adjunct systems available; Systemic/local delivery
• Recognise when to use chemotherapeutic adjuncts in periodontal disease
• Gain knowledge of the evidence to support chemotherapeutic adjuncts

Related Topics

• Plaque biofilm and periodontal disease subjects
• Mouthwashes and toothpastes modes of action

Chemotherapeutic Adjunct

• Used as form of chemical therapy as an additional aid to main treatment instead of a substitute
• Adjuncts claim to provide periodontal treatment support with antimicrobial effect targeting supragingival and within pockets
• They serve as Host Modulation Therapy, decreasing collagenase activity and aiding the tissue healing

Why Use Adjuncts?

• When in conjunction with active treatment buys time to keep biofilm growth to minimum to allow host response time to heal
• Aids acute phases and localised unresponsive sites and limitations to mechanical debridement
• Reduce/inhibit gram negative bacteria & provide patient comfort post operatively
• Useful pre-operatively to reduce bacterial load as aerosol and also post-operatively of periodontal surgery
• Indicated for rarely specific forms of periodontal disease - systemic antibiotics
• Provides placebo effect/motivation

Adjunct Limitation

• They cannot act substitute for inadequate plaque control or break up biofilm
• They are not for long term use and cannot control the disease on its own

Adjunct Systems Available

• System delivery
• Local delivery

Systemic Delivery

• The agent is taken orally then enters the stomach, where it is absorbed into blood stream
• It is then carried all over the body including the oral cavity and into the walls of PD pockets
• Some agents are more concentrated in the pocket wall, gingival tissue, and crevicular fluid than in tissue fluid

Systemic Delivery Examples

• Antibiotics: Metronidazole, Amoxicillin, Tetracyclines (e.g., minocycline, doxycycline), Azithromycin
• Systemic sub-antimicrobial doxycycline (SDD) as Host response modulators/Host Modulation Therapy; Periostat: doxycycline 20mg (synthetic tetracycline)

Advantages of Systemic Delivery

• Drug levels in crevicular fluid are comparable with serum levels, except for tetracyclines, which concentrate in GCF
• Ease of delivery
• Better access to widely distributed micro-organisms, as multiple sites receive dose

Disadvantages of Systemic Delivery

• Wide distribution agent through the body
• Development of resistant micro-organisms
• Risk of systemic side effects and drug interactions
• Agent cannot penetrate an intact biofilm
• Agent may be contraindicated in some patients, e.g., hypersensitivity
• Repeat dosing necessary for maintaining effective concentrations which relies patient adherence to take medication and to maintain plaque control
• Limited evidence of additional benefits of using various proposed adjuncts, e.g., host response modulators

Local delivery systems: apply agent to localised area using mouthwashes, gels, toothpastes, and floss and are not effective sub-gingivally

• They can only be used as an adjunct to supra-gingival plaque control
• e.g, Gingival gel (TePe)- Hyaluronic acid 0.2%, NaF 0.32% and Gengigel First Aid - Hyaluronic acid 0.12%

Local delivery systems

• Simple irrigation of pocket, using anti microbials
• Placement of preparation containing antimicrobial agent into pocket

Local Delivery Systems Examples

• Dentomycin is a minocycline 2% gel that is placed at 0, 2, 4, 6 weeks
• Chlosite is a xanthan gel containing chlorhexidine digluconate and chlorhexidine dihydrochloride 1.5%

Controlled-Delivery anti-microbial agents

• Offer controlled release that is release within <24hrs or sustained release that is >24hrs,
• The anti-microbial agent is released over a longer period of time in controlled manner
• The anti-microbial agent may be contained in a gel, chip, wax, microspheres or fibre
• e.g, Periochip which dissolve slowly over about 7-10 days

Local Delivery system examples

• Gengigel which contains 0.2% hyaluronic acid
• Curasept with 0.5% Chlorhexidine Digluconate
• Corsodyl Gel which is 1% Chlorhexidine Digluconate

Advantages of Locally Delivered Adjuncts

• Agent concentration is higher in periodontal pocket for prolonged duration with controlled / sustained delivery agents
• Higher agent concentration at site with lower overall does to patient
• Lower levels of agent systemically for less variability in patient adherence, due to professionally placed to target the site of 'active' periodontal disease

Disadvantages of Locally Delivered Adjuncts

• It takes time to place the agent delivery system
• Some agents require repeat dosing
• Agent cannot penetrate an intact biofilm & its limited effect to treated sites
• Risk of development of resistant micro-organisms
• Agent may be contra-indicated
• Relies on patient adherence to maintain plaque control
• Limited evidence of additional benefit in non-surgical periodontal treatment

Use of Chemotherapeutic Adjuncts criteria

• Patient must have a destructive periodontal condition and adequate plaque control
• Mechanical disruption of biofilm is essential, removing calculus from root surface
• Patient must adhere to use and afford the agent with no contraindications to it

Step of Therapy

• First step to guide behaviour change by motivating patients effective and consistent removal of plaque biofilm and risk factor control
• To do this, control supragingival dental biofilm and provide oral hgiene coaching
• Apply adjunctive therapies for gingival inflammation & provide Professional Mechanical Plaque Removal (PMPR)
• Control Risk factor and reassess frequently

Second Step of Therapy

• To control (reduce/eliminate) subgingival deposits do subgingival instrumentation
• Use of adjuncts; physical or chemical agents, host-modulating agent systemic or local, and subgingivally locally delivered antimicrobials

System Antibiotics

• 'Rapid rate of Progression' Grade C using 2017 classification
• Usually administered by Level 2 or 3 specialist practitioner

Third Step of Therapy

• To treat non-responding sites which are presence of pockets ≥4 mm with bleeding on probing or presence of deep periodontal pockets (≥6 mm
• Gaining access to instrument subgingival sites, to regenerate/resect lesions which make management of condition difficult through further subgingival debridement with or without adjunctive therapies through access flap periodontal surgery
• Resective periodontal surgery & Regenerative periodontal surgery

Supportive periodontal Care

• To maintain periodontal stability in treated periodontitis patients through application of preventive and therapeutic interventions of 1st and 2nd step of therapy
• Timing of recall and interventions should be tailored to patient's needs and if disease recurs- re-treatment required

Conclusions

• 'Mechanical' non-surgical periodontal treatment alone improves clinical condition in most cases.
• The success of treatment relies on plaque control maintained maintained by the patient.
• Adjunctive agents delivered locally or systemically, may improve the effect of treatment in certain situations.
• Systemic antibiotics are important in the management of generalised periodontitis diagnosed -Grade C- in younger adults and should be considered on individual case by case basis
• Localised, non-responding sites and localised recurrent disease may be treated via locally delivered antimicrobials or antibiotics
• Good plaque control and mechanical debridement are important for application antimicrobial agents and good mechanical plaque control after therapy

Explore chemotherapeutic adjuncts as chemical therapy, enhancing main treatments for periodontal disease rather than replacing them. Understand their role in supporting periodontal health with antimicrobial effects, targeting supragingival areas and pockets. This presentation covers adjunct usage, delivery systems, and supporting evidence.