Chemotherapeutic adjunct notes

Chemotherapeutic Adjuncts in Periodontal Disease

• Chemotherapeutic adjuncts are chemical therapies that support, but do not replace, main treatments for periodontal disease.
• The aim of this presentation is to understand chemotherapeutic adjuncts, suitable choices, and application methods (local or systemic).
• Key topics include existing knowledge of plaque biofilm, mouthwashes, toothpastes, and periodontal disease.
• Intended Learning Outcomes include defining chemotherapeutic adjuncts, understanding available adjunct systems (systemic/local), recognising when they are appropriate for periodontal disease, and reviewing evidence supporting their use.

What is a Chemotherapeutic Adjunct?

• It's a form of chemical treatment to support, but not replace, primary periodontal treatment.
• Adjuncts work to create antimicrobial effects, aiding tissue healing (host modulation) that can be delivered locally (within pockets) or systemically (throughout the body).

Why Use Adjuncts?

• Adjuncts aid initial treatment by keeping biofilm growth to a minimum and supporting the host's response.
• They are especially helpful for sites that don't respond to mechanical debridement.
• Reduced/inhibited gram-negative bacteria is important
• Patient comfort is improved post-operatively
• Pre-operative use to reduce potential bacterial load
• Systemic antibiotics can be used in specific, rarely-seen periodontal disease forms.
• A 'placebo effect' or motivation from treatment can also be considered.

Limitations of Adjuncts

• They cannot be used as a substitution for inadequate plaque control or biofilm disruption.
• They are not universally effective for all disease states or for long-term disease control.

Adjunct Systems: Systemic Delivery

• Systemic delivery involves taking an agent orally, allowing it to be absorbed into the bloodstream, then circulated throughout the body, including periodontal pockets.
• Some agents have higher concentrations in periodontal tissues compared to general body fluids.
• Examples of systemically administered medications include antibiotics like metronidazole, amoxicillin, tetracyclines (e.g., minocycline, doxycycline), and azithromycin.

Advantages of Systemic Delivery

• Similar drug levels in crevicular fluid and serum (except tetracyclines)
• Easy to deliver
• Reaches more widely distributed micro-organisms

Disadvantages of Systemic Delivery

• Wide distribution throughout the body, increasing potential for side effects and resistance.
• Risk of side effects and drug interactions.
• Agent may not penetrate intact biofilm, thus limiting the effect.
• Some patients may be contraindicated to treatment.
• Requires patient adherence for effective concentrations.
• Limited evidence for additional benefits.

Adjunct Systems: Local Delivery

• Local delivery methods apply the agent directly to the affected areas, limiting systemic distribution for more localised effects.
• Examples include mouthwashes, gels, toothpastes, simple pocket irrigation (using antimicrobials), directly placing antimicrobials into the pocket, and controlled-release agents (gels, chips, wax, microspheres, fibres).
• Examples of local agents include gingival gel (TePe), hyaluronic acid 2%, sodium flouride 0.32%, Gengigel first aid, hyaluronic acid 0.12% chlorhexidine, Dentomycin (minocycline 2% gel), Chlosite (xanthan gel with chlorhexidine).

Advantages of Local Delivery

• High concentration of agent is placed directly in the periodontal pocket.
• Prolonged duration of the treatment.
• Higher concentration where it's needed with lower overall dose to the patient.
• Lower systemic levels of the agent.
• Better patient adherence (sometimes due to professional placement)
• Treatment focus on 'active' sites
• Less variability in the patient's ability to adhere to treatment

Disadvantages of Local Delivery

• Placement time – the agent delivery system requires time.
• Some agents may not penetrate intact biofilm.
• Effects are limited to treated sites, potentially impacting overall disease control beyond the treated site..
• Risk of developing resistance in micro-organisms.
• Some patients may be allergic.
• Relies on patient adherence for plaque control.

Criteria for Adjunct Use

• Adequate plaque control is essential
• Mechanical disruption of the biofilm is vital.
• Sufficient calculus removal from the root surface is necessary for optimal results
• The patient must have a plaque-related destructive periodontal condition
• The patient must have adequate means to continue treatment adherence
• The agent must not be contraindicated to the patient

First Step of Therapy

• Initial therapy focuses on motivating patients for effective and consistent plaque biofilm removal and risk factor control.
• Procedures include educating the patient on supra-gingival dental biofilm control, and delivering oral hygiene coaching.
• Adjunctive therapies, professional mechanical plaque removal (PMPR), and risk-factor control are covered in this step.

Second Step of Therapy

• The goal here is to address sub-gingival deposits.
• Methods include sub-gingival instrumentation and additional use of physical or chemical agents, host-modulating agents (local/systemic), locally delivered antimicrobials, and systemic antimicrobials.

Third Step of Therapy

• This step focuses on the non-responsive sites with pockets ≥4 mm, bleeding on probing, deep periodontal pockets (≥6 mm).
• Methods include further sub-gingival debridement, access flap periodontal surgery, resective periodontal surgery, and regenerative periodontal surgery.

Supportive Periodontal Care

• This step aims for long-term periodontal stability.
• Procedures include the application of preventive and therapeutic interventions in the initial two steps, and customized timing of those interventions, based on the patient’s needs.
• Retreatment may be necessary if periodontal disease recurs

Evidence for Adjunct Use

• Recent BSP (British Society of Periodontology) guidelines advise on the timing and implementation of chemotherapeutic adjuncts during treatment, based on Stage I-III Periodontal Disease.
• Based on specific cases, the treatment recommendations for different kinds of adjuncts (local and systemic) are considered.

Additional Conclusions

• Mechanical non-surgical periodontal treatment usually suffices for most cases.
• Patient plaque control is the critical factor for successful treatment.
• Adjuncts may further improve treatment outcomes in specific scenarios.
• Systemic antibiotics should be carefully considered on a case-by-case basis, potentially being useful for certain forms of generalized, younger-adult periodontitis.
• Localized, non-responding sites, and recurrent disease can be targeted with localised antimicrobials or antibiotics.
• Proper plaque control and mechanical debridement are essential before and after adjunct therapy application.

This quiz explores the key factors that influence the success of periodontal treatment. It highlights the role of systemic antibiotics, preventative strategies, and the importance of antimicrobial application in periodontal therapy. Ideal for dental students and practitioners seeking to enhance their understanding of periodontitis management.