Chemotherapeutic Adjuncts in Periodontal Disease PDF

Chemotherapeutic (adjuncts) in periodontal disease Tutor: Ms P Lazarou Module: FCSP  Aim To gain knowledge of what a chemotherapeutic adjunct is when used in the treatment of plaque related periodontal disease and to recognise which adjunct to use, whether locally or systemically de...

Chemotherapeutic (adjuncts) in periodontal disease Tutor: Ms P Lazarou Module: FCSP  Aim To gain knowledge of what a chemotherapeutic adjunct is when used in the treatment of plaque related periodontal disease and to recognise which adjunct to use, whether locally or systemically delivered and if appropriate, how to use it  Intended Learning Outcomes Define the term chemotherapeutic adjunct Be familiar with adjunct systems available: systemic delivery/local delivery Recognise when to use chemotherapeutic adjuncts in periodontal disease View the evidence to support the use of chemotherapeutic adjuncts in periodontal disease GDC LO’s: 1.1.1 1.1.8 1.11.7 Related topics Draw on your existing knowledge of: Plaque biofilm Mouthwashes and mode of actions Toothpastes and mode of actions Periodontal Disease subjects Chemotherapeutic adjunct  What is a chemotherapeutic adjunct? A form of chemical therapy which is an additional aid to the main treatment. As a subsidiary (NOT a substitute) What are the ways in which adjuncts claim to support Review mo uthwashes periodontal treatment? and toothp aste sessions Antimicrobial effect Supragingival Within pocket Host Modulation Therapy: decrease collagenase activity and aid in tissue healing  Why use adjuncts? In conjunction with active treatment ? Buys time to keep biofilm growth to minimum allowing host response time to heal Acute phases Aid when there are localized unresponsive sites & limitations to mechanical debridement Reduce/inhibit gram negative bacteria Patient comfort post operatively Pre-operative use to reduce bacterial load in aerosol? Periodontal surgery post-operatively Rarely-specific forms of periodontal disease - systemic antibiotics Placebo effect/motivation?  Adjuncts cannot: Act as a substitute for inadequate plaque control Break up biofilm Be used long term Control disease Adjunct systems available: systemic delivery/local delivery Systemic delivery The agent is taken orally, enters the stomach, is absorbed into the blood stream and then is carried all over the body including the oral cavity and into the walls of periodontal pockets. With some agents, the agent is actually more concentrated in the periodontal pocket wall, gingival tissue and crevicular fluid than in the tissue fluid Systemic Delivery a) Antibiotics: Metronidazole Amoxicillin Tetracyclines e.g. minocycline, doxycycline pharmaceutical-medicines.com Azithromycin b) Systemic sub-antimicrobial doxycycline (SDD) as Host response modulators/Host Modulation Therapy: Periostat: doxycycline 20mg (synthetic tetracycline) Image ref: nature.com  Advantages of systemic delivery  Drug levels in crevicular fluid are comparable with serum levels except tetracyclines which are concentrated in GCF  Ease of delivery  Will reach more widely distributed micro-organisms better as multiple sites will receive dose Disadvantages of systemic delivery  Wide distribution of 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 contra-indicated in some patients e.g. hypersensitivity to the therapeutic agent  Repeat dosing necessary for maintaining effective concentrations.  Relies on 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 These are methods of applying an agent to a localised area. a) Use of mouthwashes, gels, toothpastes and floss. None of these will be effective sub-gingivally. They can only be used as an adjunct to supra-gingival plaque control. www.gengigel.co.uk Examples: Gingival gel (TePe)- Hyaluronic acid 0.2%, NaF 0.32% Gengigel First Aid - Hyaluronic acid 0.12% www.mouthulcers.co.uk Local delivery systems cont… b) Simple irrigation of the pocket, using anti-microbials c) Placement of a preparation containing an antimicrobial agent into the pocket www.researchgate.net Examples of local delivery systems continued... Dentomycin: minocycline 2% gel placed at 0, 2, 4, 6 weeks dhb.co.uk Chlosite: xanthan gel with chlorhexidine digluconate & chlorhexidine dihydrochloride 1.5% Swallowdental.co.uk  Researchgate d) Controlled-delivery anti-microbial agents controlled release, sustained release controlled 24hrs With these systems, the anti-microbial agent is released over a longer period of time in a controlled manner. The anti-microbial agent may be contained in a gel, chip, wax, microspheres or fibre. Example: Periochip  dissolve slowly over about 7-10 days Nature.com e) Placement of a gel containing other agents into the pocket Examples: Gengigel 0.2% hyaluronic acid Curasept 0.5% Chlorhexidine Digluconate Corsodyl Gel 1% Chlorhexidine Digluconate researchgate.net  Advantages of locally delivered adjuncts  High concentration of agent in the periodontal pocket  Prolonged duration of high concentration (with controlled / sustained delivery agents)  Higher concentration of agent at site achieved with lower overall dose to patient.  Lower levels of agent systemically.  Less variability in patient adherence (professionally placed)  Targets the site of ‘active’ periodontal disease Disadvantages of locally delivered adjuncts  Time to place the agent delivery system  Some agents require repeat dosing  Agent cannot penetrate an intact biofilm  Effect limited to the treated sites  Risk of development of resistant micro- organisms  Agent may be contra-indicated in some patients e.g. hypersensitivity to the therapeutic agent  Relies on patient adherence to maintain plaque control  Limited evidence of additional benefit in non- Use of chemotherapeutic adjuncts  Must be a plaque-related destructive Patient must periodontal have adequate condition Must be able (good) plaque to afford the control agent Criteria for Mechanical adjuncts use No contra- disruption of indication to biofilm is the use of the essential agent Calculus must have been Patient removed from adherence root surface 1. First step of therapy AIM: guide behaviour change by motivating patients in effective and consistent removal of plaque biofilm and risk factor control. HOW? Supragingival dental biofilm control Oral hygiene coaching Adjunctive therapies for gingival inflammation Professional Mechanical Plaque Removal (PMPR) Risk factor control: health behaviour change Reassess frequently 2. Second step of therapy AIM: to control (reduce/eliminate) subgingival deposits HOW? Subgingival instrumentation Use of adjunctive physical or chemical agents Use of adjunctive host-modulating agents (local/systemic) Use of adjunctive subgingivally locally delivered antimicrobials Use of adjunctive systemic antimicrobials When may the use of systemic antibiotics be considered for periodontal disease? ’Rapid rate of Progression’ (2017 classification) Grade C Usually administered by Level 2 or 3 specialist practitioner  3. Third step of therapy AIM: to treat non-responding sites (presence of pockets ≥4 mm with bleeding on probing or presence of deep periodontal pockets (≥6 mm), to gain access to instrument subgingival sites, to regenerate/resect lesions which make management of condition difficult HOW? Further subgingival debridement with or without adjunctive therapies Access flap periodontal surgery Resective periodontal surgery Regenerative periodontal surgery  4. Supportive periodontal care AIM: to maintain periodontal stability in treated periodontitis patients HOW? Application of preventive and therapeutic interventions of 1st and 2nd steps of therapy Timing of recall and interventions should be tailored to the patient’s needs If disease recurs- re-treatment may be required- diagnosis and treatment plan to be carried out What does the evidence say? When should we use chemotherapeutic adjuncts? What do the most recent BSP implementation of European S3 guidelines advise? https://doi.org/10.1016/j.jdent.2020.103562 Conclusions ‘Mechanical’ non-surgical periodontal treatment alone improves the clinical condition sufficiently in most cases. The main factor which will determine the success of treatment will be the standard of the plaque control maintained by the patient. Adjunctive agents delivered locally or systemically, may improve the effect of treatment in certain situations.  Conclusions cont... Systemic antibiotics may be important in the management of some forms of generalised periodontitis diagnosed -Grade C- in younger adults: consider on individual case by case basis. Localised, non-responding sites and localised recurrent disease may be treated with locally delivered antimicrobials or antibiotics. Good plaque control and mechanical debridement before the application of any antimicrobial agents and good mechanical plaque control after therapy are essential for treatment success. References/further reading Gehrig, J. Shin, D. Willman, D. (2018) Foundations of Periodontics for the Dental Hygienist, 5th ed West,N et al. (2021) BSP implementation of European S3 - level evidence-based treatment guidelines for stage I-III periodontitis in UK clinical practice, Journal of Dentistry, 106 (2021) 103562. DOI: https://doi.org/10.1016/j.jdent.2020.103562 BSP (2016) Good Practitioners Guide.[online] good_practitioners_guide_2016.pdf (bsperio.org.uk) [Accessed June 2021] Extra slides relating to the BSP implementation of European S3 paper  BSP implementation of European S3 guidelines  Systemic antibiotics A) Not recommended to be used routinely in patients with periodontitis: Grade of recommendation- Grade A - (recommend not to) Reasons? B) Specific systemic antibiotics may be considered for specific patient categories (e.g. generalised periodontitis Grade C in young adults) Grade of recommendation- Grade 0 - (may be considered)