Chemotherapeutic Adjuncts in Periodontal Disease

Chemotherapeutic Adjuncts in Periodontal Disease

• Chemotherapeutic adjuncts are chemical therapies used alongside, not instead of, the primary treatment.
• Their purpose is supporting periodontal treatment, not replacing it.
• Adjunctive therapies work by various mechanisms, including antimicrobial effects and host modulation.

Aims of the Module

• Understand what a chemotherapeutic adjunct is in periodontal disease treatment.
• Identify the appropriate adjunct based on delivery method (systemic or local).
• Determine if an adjunct is suitable and how to use it.

Intended Learning Outcomes

• Define the term "chemotherapeutic adjunct."
• Understand available adjunct delivery systems (local and systemic).
• Learn when to use chemotherapeutic adjuncts in periodontal disease.
• Review the evidence supporting the use of adjunctive therapies for periodontal disease.
• The learning outcomes are linked to specific GDC (General Dental Council) learning objectives.

Related Topics

• Students should draw on existing knowledge of the following topics:
  • Plaque biofilm
  • Mouthwashes (and their modes of action)
  • Toothpastes (and their modes of action)
  • Periodontal disease

What is a Chemotherapeutic Adjunct?

• A chemotherapeutic adjunct is a chemical treatment used as a supplementary aid to the main periodontal therapy.
• They are used to support, not replace, the core treatment.
• The adjuncts aim to provide antimicrobial effects (killing bacteria) and host modulation (improving tissue healing).

Why Use Adjuncts?

• Adjunctive treatments provide extra support.
• They buy time before a host response can take hold.
• They support active treatment by improving and reducing biofilm growth.
• Useful for localized unresponsive sites where mechanical debridement is limited.
• Reduce gram-negative bacteria post-operatively.
• Generally useful when combined with other surgical or mechanical interventions.

Adjuncts Cannot

• Substitute for adequate plaque control.
• Break down biofilm on their own.
• Be used long-term as a constant treatment.
• Control periodontal disease by themselves.

Adjunct Systems Available

• Systemic delivery (administered orally)
• Local delivery (applied directly to the affected area e.g. mouthwashes, gels, irrigations)

Systemic Delivery

• The agent is absorbed into the bloodstream, then distributed throughout the body, including the oral cavity and periodontal pockets.
• Some drugs are more concentrated in periodontal areas.
• This approach allows treatment to affect the whole body.

Types of Systemic Adjuncts

• Many antibiotic classes,
• e.g. Metronidazole, Amoxicillin, Tetracyclines (Minocycline, Doxycycline), Azithromycin

Systemic Delivery Advantages

• Easy administration.
• Drug levels are comparable to serum levels (except some tetracyclines) in the crucial crevicular fluid tissue.
• May access a wider distribution of micro-organisms.

Systemic Delivery Disadvantages

• Wide distribution throughout the body can cause side effects and lead to the development of resistant microorganisms.
• Difficult to target affected sites directly.
• Requires patient effort for long term adherence to treatment plans.

Local Delivery Systems

• These systems directly apply the agent to a localized area.
• Mouthwashes, gels, toothpastes, and floss are examples.
• They can only be used for supra-gingival plaque control.

Local Delivery System Types

• Examples include:
  • Gingival gels (e.g., TePe, Gengigel, containing fluoride or other antimicrobials).
  • Solutions applied for irrigation of gingival pockets
  • Controlled-delivery agents that release medication over a prolonged time (e.g., periochip).
  • Placement of preparations into the pockets.

Local Delivery Advantages

• Concentrated effects in treatment areas.
• Reduced systemic side effects (compared to systemic administration).
• May maintain the plaque control in affected areas.

Local Delivery Disadvantages

• Requires professional application in most cases
• Can be time-consuming to place.
• Patient compliance can influence treatment efficacy.

Use of Chemotherapeutic Adjuncts

• Plaque control and calculus removal are pre-requisites.
• The patient must exhibit good (adequate) plaque control habits.
• Mechanical disruption of biofilm is essential.
• Consider factors like patient adherence, cost, convenience and specific needs.

First Step Therapy

• Focuses on patient behavior modification for plaque biofilm and risk factor control.
• Emphasizes consistent plaque biofilm and risk factor control.
• Methods include: supragingival cleaning; oral hygiene training; professional or mechanical methods of plaque removal; patient education on health behavior change.

Second Step Therapy

• Targets subgingival deposits (biofilm and calculus).
• Subgingival instrumentation is a crucial initial step.
• Also consider adjunctive (additional, supporting) chemical agents; host-modifying agents; subgingivally administered antimicrobial agents; and systemic antimicrobials.
• Only initiate this step when a patient is engaged in the process; when the first phase is successful; and when subgingival deposits exist.

Third Step Therapy

• Targets non-responsive sites with deep pockets.
• Aims at addressing persistent problems.
• Treatment options may include further debridement, access flap surgery, periodontal surgery (resection or regeneration) and/ or specific types of localized advanced treatment procedures.

Supportive Periodontal Care

• Aims to support and maintain treatment, improving periodontal stability.
• Tailoring therapy timing to individual needs ensures long term effectiveness
• Recurrence of disease requires re-evaluation, diagnosis and further treatment if needed.

Evidence-based recommendations on adjunct use

• Review of current evidence supports the approach to using particular types of adjunct therapies based on factors like severity of gingival conditions; sites affected; and other patient-specific considerations.

Additional Points Regarding Systemic Antibiotic use.

• Systemic antibiotics are not a first-line treatment; are not routinely administered; and should be considered only for specific patient populations.
• The use of antibiotics should only be implemented when indicated by a specialist based on the unique aspects of each case and individual risk factor identification.

Summary of Conclusions

• Mechanical (non-surgical) treatment often resolves the situation without additional pharmacological treatments.
• Plaque control by the patient plays a critical role in the success of periodontal treatment.
• Adjunctive agents (local and systemic) can sometimes, in specific situations, improve the effectiveness of periodontal treatment.

This quiz explores the role of chemotherapeutic adjuncts in the treatment of periodontal disease. Participants will learn about the definitions, delivery methods, and clinical applications of these adjuncts. Understanding when and how to incorporate these therapies can significantly enhance periodontal treatment outcomes.