NOTE: This powerpoint is on the web. Periodontal Pharmacotherapeutics 1) Topical 2) Local 3) Systemic 1) Topical a. Anti-plaque compounds i. Phenolic compounds: Listerine ii. Quaternary ammonium compounds: Scope, Sepical, Viadent iii. Sanguinarine: Viadent iv. Alexidine: Second Generation – effective and long lasting v. Octinidine: Second Generation – effective and long lasting vi. Chlorhexidine: Second Generation – effective and long lasting 1. The only one brought to the commercial market 2. Peridex and Periogard b. Substantivity: the amount of time the anti-microbial concentration is effective in the mouth. Second generation are more substantive. Plaque index: he showed us a graph that tracked the plaque index. The chlorohexadine performed the best. A second generation antimicrobial. Gingival index: (scores inflammation) all of the first generation antimicrobials did better than the control, but the chlorohexadine did significantly better. Dosage of chlorohexidine: 2 x daily (half the cap full: .5oz) for 30 seconds. Side effects: Extrinsic staining Taste alteration Increased supragingival calculus – it will kill bacteria, but it doesn’t remove it from the mouth, so it can accumulate after it’s dead. Oral irritation Total Toothpaste: Antiplaque Antigingivitis Both due to the triclosan and copolymer. The Copolymer binds to the plaque, and the triclosan binds to the copolymer. Provides substanstivity. Toothpaste and chlorohexadine don’t mix due to binding of molecules. Sodium laurel sulfate. Directions: brush and rinse with water first to get rid of the SLS, then use the chlorohexadine. 2) Local administration a. Can be patient administered (like via a water pick) but patient compliance can be problematic b. Professional Irrigation: proferred c. Local Sustained Release i. Problems: Are less absorbable when compared to systemic doses. ii. Four have come to market 1. Actisite: 1994 delivers tetracycline a. Comes in a cord type (fibers) that is 12.7mg that provides huge concentrations in the pocket. Compare with 1000mg systemic which doesn’t even compare to the local delivery concentration. b. Product must be glued in place, and the glue must be removed. c. Not on the market anymore 2. PerioChip: 1998 antimicrobial! The only antimicrobial! a. Active ingredient is chlorhexadine – no resistance issue b. Easy to insert c. Bioabsorbable d. Periodontal absesses may develop due to graded effect (the tissue at the gingival margin can get healthy faster than the apex that may lead to perioabsess – so restrict to one surface). 3. Atridox: 1998 Diocyclin sp? Tetracyclin family a. Two syringe system b. Plunger 100 times! c. Doesn’t reabsorb as fast as periochip 4. Arestin: minocycline - Tetracyclin family a. Used in the clinic b. Microsphere technology c. Easily adhires to the pockets d. Absorbs at the same rate e. Effective for about two weekss. f. Requires a special syringe tip, and special unit doses g. Can place multiple cartridges per tooth. 3) Antibiotic Therapy a. Use systemic antibiotics only if there is an indication of a systemic problem. b. Do not use for garden variety periodontitis. c. For: acute infections, aggressive periodontitis, refractory periodontitis. d. The most commonly used for refractory or aggressive periodontitis is Metronidazole & Amoxicillin 250mg/BID/8 days e. Periostat: doxycycline. Used in a sub-antimicrobial dose. Patient must be on the meds for a minimum of three months. Bone loss / attachment loss is due to the host response. Periostat targets the colagenases that are associated with this attachement loss. MMP1 is the collagenase associated with normal collagen turnover which is not affected by this med’s. MMP8 and MMP9 are the one’s affected. f. Don’t lie down for an hour after you take the medication. 4) Dentin Hypersensitivity a. Characterized by short, sharp pain arising form exposed dentin in response to stimuli typically thermal, evaporative, tactile, osmotic, or chemical and which cannot be ascribed to any other form of dental defect or pathology. b. Explained by: i. Hydrodynamic theory. 1. Dentin made up of tubules. Fluid flow evoked by stimuli 2. Activates A-delta intradental nerves 3. Mechanoreceptors are disturbed due to flow of fluid which responds and distorts the pupal nerves. a. Heat: inward flow, slow dull pain b. Cold: outward flow 4. Hypersensitive dentin has 8x the amount of tubules, AND the diameter of the tubules are 2x. The size probably makes the most impact. 5. the most sensitive is right at the DEJ. c. Two processes must happen i. Lesion localization: The dentin must be exposed. 1. due to gingival recession, attrition, abrasion, erosion, abfraction. 2. Lesion Initiation: The dentin tubule system has to be open and patent to the pulp. a. Due to lots of stuff. d. Symptoms can be caused by: i. Caries ii. Cracked teeth iii. New restoration iv. Occlusal trauma v. Bleaching vi. Other e. Management: i. First choice: Desensitize the root tubules via 1. potassium nitrate or strontium chloride ii. other: (pick all of the above) iii. graft iv. guided tissue regeneration – keeps epithelial cells from migrating down.