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LOTIONS_ POTIONS_ PASTES AND MOR

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					LOTIONS, POTIONS, PASTES
                                                   Medication Usage
       AND MORE!
                                              Adults over age 65 use one or
                                             more medications daily
                                             Over 30% take 3 or more
                                             medications daily
                                             Increased usage decreases
                                             compliance


  This course is sponsored in part by an
 educational grant from Johnson & Johnson




                                                 DRUGS & ALLERGIC
   Food Drug Interactions
                                                    REACTIONS
Grapefruit juice can increase
serum blood levels of drugs                                      OIL OF WALNUT
                                            PENICILLIN           ASPIRIN
                                            AMOXICILLIN,AMPICI   TARTRAZINE(5)
M t     il   d   t id
Metamucil and antacids can                  LLIN
                                                                 CINNAMON
decrease the absorption of drugs            PABA ANESTHETICS
                                            IODINE
Tannins in tea can decrease
absorptionof iron




          Drugs Most
     CommonlyAssociated
   With Fixed Drug Eruption
Barbiturates     Phenolpthalein
Clotrimazole          y
                 Salicylates
Dapsone          Sulfonamides
Phenothiazine    Tetracycline
derivatives




                                                                                 1
       Sulfite Allergy
                                                          NSAID’S Precaution
 5-10 % of asthmatics

 Used as food preservatives in
 Salads, fresh fruits, potatoes wines, shellfish      y                 p            p y
                                                   May cause bronchospasm or anaphylaxis in
                                                     aspirin sensitive asthmatics, especially
 Found in hair preparations, eye                                           triad”-
                                                    those with an “aspirin triad”-nasal polyps,
 and ear products, and antifungals                           asthma, & aspirin allergy




    Medications as a Risk Factor for                 DRUGS AFFECTING ORAL TISSUE
         Periodontal Disease
                                                                Tetracycline
 Behavioral Alteration                                         Anticoagulants
 Plaque Composition & Ph                                          Dilantin
 Salivary Flow                                           Calcium Channel Blockers
 Gingival Crevicular Fluid                                      Cyclosporin
 Flow                                                      Anticholinergic Drugs
 Gingival Tissue Effects                                     Birth Control Pills
 Alveolar Bone Effects                                        Lead Perborate
                                                    Bismuth & Mercury- containing Agents
                                                              Antimetabolites
                                                      Non-Steroidal Anti-inflammatories




Bisphosphonates & Alveolar Bone                            Bisphosphonates
 Data based on 2 year review of                     Risk of Bone Osteonecrosis (BON) is
                                                    0.7/100,000 with oral dose
 charts of patients
 Usually find 4-6 patients with                     Probability may be increased in patients
                                                    taking steroids or estrogens, over 65, and
                                                         g                  g   ,        ,
 osteonecrosis of alveolar bone                     long term use of bisphosphonates (based on
                                                    IV data)
 Survey found 63 patients with
                       medicated-
 problem while being medicated-7                    Effects of Bisphosphonates are long lasting
 were on oral bisphosponates for                    after cessation of therapy
 osteoporosis-others for cancer
 osteoporosis-
                                                    Over 22 million prescriptions/yr. in USA




                                                                                                  2
Bisphonates & Alveolar Bone                     Oral and IV Bisphosponates
Patients being medicated with
Bisphosponates (alendronate, etidronate,
                 (alendronate,                    Brand Name/Generic Name
ibandronate, iludronate, risedronate) may
                         risedronate)            Actonel,risedronate,
                                                 Actonel,risedronate,
develop necrosis of alveolar bone                 Boniva,ibandronate,Fosamax,alendro
                                                  Boniva,ibandronate,Fosamax,alendro
                                                   nate,Skelid,
                                                        ,                   , Didronel,
                                                  -nate,Skelid, stiludronate, Didronel,
Patients medicated IV for metastatic cancer       etidronate
may be at increased risk (parmidronate,
                         (parmidronate,       IV
                        Acid)
clodronate, zolendronic Acid)                 1.    Aredia, pamidronate, Zometa,
                                                    Aredia,
                                                  zolendronic acid , Bonefos ,
Implant failure may occur in these patients       clodronate




                                                   Bisphosphonate Patient
       Bisphosphonates
                                                       Considerations
Inform patient of possibility, stress         Use of CHX/Listerine Mouthrinse for
rare                                          2 months
Treat one quadrant/site, wait 2
                                                     Amoxicillin,
                                              Rx for Amoxicillin, 500mg, TID,14
months
                                              days or
Place patient on topical antimicrobial
rinse for the 2 months-consider
                months-                       Metronidazole, 250mg, TID, 14 days
                                              Metronidazole,
antibiotcs                                                    or
Chlorhexidine is best but because of          Clindamycin,
                                              Clindamycin, 300mg, TID, 14 days or
staining can alternate with Listerine
                                              Azithromycin, 250mg, QD, 10 days
                                              Azithromycin,
Dentifrice used should be antiseptic




         BON Symptoms
Pain, soft tissue swelling
Infection
Loosening of Teeth
Drainage
Bone exposure
May mimic periodontal disease




                                                                                          3
                                              Captopril
         Ace Inhibitors
                                    Accupril
  Angioedema*                       Altace
  Lichenoid lesions                 Capoten
  Mucositis
  M     iti                         Lotensin
                                    Monopril
  Hoarse voice
                                    Prinivil
                                    Univase
*Also seen with denture adhesives
                                    Vasotec




                                         CAUSES OF GINGIVAL
                                           ENLARGEMENT
                                               SYSTEMIC
   CAUSES OF GINGIVAL                 FAMILIAL     CYCLOSPORIN
     ENLARGEMENT                      SCLERODERM
                                      PREGNANCY
                                                   CALCIUM
                                                   CHANNEL
                                      PUBERTY           BLOCKERS
               LOCAL                               AMPHETAMINES
                                                   DILANTIN
                                                   BARBITURATES
       NON-RESTORED TEETH
       NON-
             HABITS
        MOUTHBREATHING




                                        DRUGS & GINGIVAL
   Calcium Channel Blockers              ENLARGEMENT

   Nifedipine(Procardia)            Phenytoin(dilantin)
   Verapamil(Calan)                 Cyclosporin
   Diltiazem(Cardizem)              Calcium Channel Blockers
   Amlodipine(Norvasc)              Amphetamines?




                                                                   4
         Herbal Products

                        500%
Usage has increased by 500% from
1997-
1997-2009
180% increased in high doses of
vitamins
1/5 of population take prescription
drugs , vitamins & herbs




                                             Home Remedy for Pyorrhea
                                                                Tips 1:
                                                        Chew a very green Guava.

                                                                  Tips 2:

                                       Drink 1 cup of spinach juice mixed with 1 cup of carrot juice.

                                                                  Tips 3:

                                       Eat a ripe Banana by only removing the outer peel very gently.

                                                                  Tips 4:

                                            Eat the Banana along with the threadlike inner peel.

                                                      Source www.medindia.org. 2006




         Herbal Products              Herbal Agents : Liver Toxicity
 Bleeding                             Chaparral
 Xerostomia                           Coltsfoot
 Decreased wound healing              Comfreyy
                                      Germander




                                                                                                        5
       Herbal Agents :
                                                Herbal Agents: Bleeding
    Cardiovascular Toxicity
                                            Gingko
Ephedra may increase response
                                            Garlic
to epinephrine including
                                            Ginseng
dysrhythmia
                                            Ginger
 Cocaine sensitizes heart to
                                            Chamomile
dysrhythmia to local anesthetics
  Ginsing can cause arrhythmia




Herbal Agents : Miscellaneous               Dangerous Dietary Supplements

Licorice may potentiate the                 Ephedra-cardiac arrhythmia
                                            Ephedra-
effect of corticosteroids                   Citrus aurantitium(bitter
Feverfew and NSAID’S may                    orange)-
                                            orange)-cardiac arrhythmia
increase apthous ulcers                     U i acid (
                                            Usnic               loss)-li
                                                           i ht loss)-liver
                                                     id (weight l   )
                                            damage
Eichinacea may inhibit
                                                          uses)-
                                            Kava (varied uses)-liver damage
healing & increase post
                                            Pyrrolizidine alkaloids (varied
surgical infection
                                            uses)-
                                            uses)-Liver damage




 Interactions : Herbal Agents                        ADA Guidelines
                                            -   six month studies ( 2 )
Ginkgo , Garlic ; Danshen , & Dong quai -
bleeding episodes in conjunction with       -   Safety to oral tissues
anticoagulants
St John s wart -decrease levels of
St. John’s                                  -                                 y
                                                Clinical & statistical efficacy
anticoagulants , cardiac and                -   No adverse microflora effects
antihypertension meds
Valerian, Kava-
Valerian, Kava-sedatives to produce         -   Plaque reduction Must be
oversedation                                    associated with gingivitis
Ginsing-cardiovascular complications
Ginsing-                                        reduction
(arrhythmia) with epinephrine




                                                                                  6
Commonly Studied Antiseptics                    Fluorides
Chlorhexidine                          Stannous Fluorides 0.04%,
Essential oils                          0.1% , 0.4%
Cetylpyridinium chloride
Stannous fluoride                      A id l t d h    h t fluoride
                                       Acidulated phosphate fl  id
Triclosan                               1.23% - 2.5%
Zinc citrate
                                       Sodium fluoride 0.24% - 0.5%




                                           Root Caries Incidence
Fluoride Content of Dentifrices
                                                       By age 45, 33% have
  1 inch=1.5 grams=1.5mg of fluoride                   adult root caries
                                                               64
                                                       By age 64, 59% have
                                                       adult root caries
                                                       91% of root caries
                                                       can be arrested by
                                                       use of fluorides
                                                       1Burton,
                                                              JADA, Jan. 1994
                                                       2Miller,
                                                             Natl. Survey Oral-Health in
                                                       US
                                                       3McGuire, J Clin. Dent. 1993




 Fluoride Varnishes
Duraphat-          Fluoride-
Duraphat-5% Sodium Fluoride-over 200
clinical studies

          Varnish-
Prevident Varnish-same manufacturer
   Duraphat
as D    h t

Duraphlor-generic copy-no clinical
Duraphlor-        copy-
studies

      Protector-
Fluor Protector-0.9%Fluorsilane




                                                                                           7
Colgate® PreviDent® Varnish                                                  Root Surface Caries: Therapy
                         Active Ingredients                                  Topical fluorides
                                                                            Prevident, Gel-kam,
                                                                            Prevident, Gel-kam,
                         • 5% sodium fluoride (22,600 ppm)

                         Benefits
                         • Ready-to-use unit dose treatment                 Minute Foam
                         • Translucent color to guide application, but
                           dries transparent on teeth                       P   id t Cl      D    h t
                                                                                       Clear,Duraphat,
                                                                            Prevident Clear,Duraphat,
                                                                            Durafluor
                         • Highest fluoride concentration available for
                           clinically proven for hypersensitivity relief
                         • Sets rapidly on contact with saliva
                         • Less risk of fluoride ingestion than with        Remineralization
                           conventional topical fluorides

                         Patient Problems                                   Trident White, Amorphous
                         • Hypersensitivity: post scaling / root planing,
                           post perio surgery, root exposure
                                                                            CaPo4, MI Paste




                                                                            Remineralization, i.e. Amorphous
                                                                                 Calcium Phosphate:
                                                                                Recaldent, Enamelcare
                                                                                           Remineralization



                                                                                           Demineralization
                                                                                           D i     li i




     www.parnellpharm.com




Amorphous Calcium Phosphate                                                  Adverse Effects of Hydrogen
          “ACP”                                                                       Peroxide
               Seconds
   Ca++
                              Gel                                           May delay wound healing
          -3
  (PO4)
                                                                              y                   j y
                                                                            May increase tissue injury
                                    Under 2 minutes

                                          A     h
                                          Amorphous
                                          Precipitate                                co-
                                                                            May be a co-carcinogen
                                    Several hours




                  Crystalline
                 Hydroxyapatite




                                                                                                               8
Oral Antimicrobials: 6 Month or Longer                                    Cetylpyridinium Chloride
                    # Usage Subj %PI %GI                  Anticandida   Active ingredient in Advanced
  Chlorhexidine      6 BID      1516    21-61   18-67        +++
                                                                        Care Viadent, Cepacol, Scope,
   Essential Oils    11   BID   2540    19-56   15-37         ++
                                                                        Pro-
                                                                        Pro-Health
   Cetylpyridinium 3      BID   450     14-28    8-37          +
                                                                        Stains teeth in 10% of patients
   Stannous Fl       3    BID    913    0        0
                                                                        Acitivity decreased by dentifrice
                     2
                     2
                          BID
                          BID
                                 145
                                 744
                                        0-77
                                        0
                                                 45-72
                                                 20
                                                                        ingredients, serum
                     2    BID    316    0-7       22-26
                                                                        May decrease bond strength,
   Triclosan         9 BID       1400   12-30    20-75                  discolor restorations
   Zinc Citrate      1 BID       113    25       19




  Anti-
  Anti-inflammatory Effects                                                 Anti-
                                                                            Anti-inflammatory Effects of
                                                                                    Essential Oils
       of Essential Oils
                                                                        The preliminary findings presented
       The mixture of essential oils                                    here suggest that, when in a fixed
  significantly inhibited mPGE2S with a                                 combination, the four EOs may be
  50% inhibitory concentration (IC50)                                   useful in reducing PGE2 levels in the
                 of 0.004%.                                             oral environment and, hence, have
                                                                        anti-inflammatory properties.
                                                                        anti-
                                  Synthase-
     Microsomal Prostaglandin E Synthase-1 Inhibition by
   Antiseptic Mouthrinse Essential Oils J. GIERSE,et al, JDR,                                       Synthase-
                                                                         Microsomal Prostaglandin E Synthase-1 Inhibition by
                            2006                                        Antiseptic Mouthrinse Essential Oils J. GIERSE,et al, JDR,
                                                                        2006




           Microbiology Studies
                                                                        Microbiological Conclusions
           TRICLOSAN (Total)
 Research Pathoge                      Opportunis Resist                                    Triclosan-
                                                                        Long term use of a Triclosan-
          n                            t                                co-polymer dentifrice does not
                                                                        co-
 Zambon no                             no         no                    result in the development of
                                                                        pathogenic
                                                                        pathogenic, opportunisitic or
 Bontá              no                 no                    no
                                                                        resistant oral microorganisms
 Walker             no                 no                    no

 Zambon             no                 no                    no

 Fine               no                 no                    no




                                                                                                                                     9
    Triclosan: New Data    Simplified Pathway for Gingival Inflammation

Inhibits cytokines                   Pathogenic Flora                    Triclosan

Inhibits mediators of               Products (LPs, etc.)
inflammation-pge2,
inflammation-
cyclooxygenase                      Cytokines &
                                    Inflammatory                         Triclosan
                                      Mediators


                                     Inflammation & Tissue Destruction


                                   Bone Resorption/Pockets (Perio)




                                   Ph of Mouthrinses

                            Plax                                 7.6
                            Cepacol-reg/mint
                            Cepacol-                             7.0/6.0
                                      Perio-
                            Peridex, Perio-Gard                  5.5
                            Scope                                5.4
                            Viadent                              4.8
                            Listerine                            4.2




          Drinks-
     Soft Drinks-ph           Buffering Effect of Saliva
 Diet Coke          3.29    30 sec. rinse with Listerine vs. water
 Diet Pepsi         3.05    Lingual Plaque ph recorded at 0, 30,
 Nestea             3.04    60, 120 secs. post expectoraton
 Gatorade           2.95    Ph was 6.73 to 5.04 to 5.78(30 sec.)
 Dr. Pepper         2.92    to 6.74 (120 sec.) vs. 6.56
 Hawaian Punch      2.82    No changes in calcium, phosphate or
 Orange Soda        2.80    organic acids compared to water
 Coke               2.53
 Pepsi              2.49                            Nazahi, Lynch 1998




                                                                                     10
             CONTENT-
     ALCOHOL CONTENT-%
                                         Average Urethane Level (ppb)
Listerine l          26.9
  Listerine ll       21.6                Brandy (grape)        10/45
                                         Brandy (fruit)        5/255
Scope                18.5                Bourbon               70/55
                                         Rum                   2/5
                                         Scotch                */55
Cepacol              14.0%
                                         Sherry                10/40
                                         Grape Wine            10/15
Peridex, PerioGard 11.6%                 Sake                  55/60

Viadent              11.5%




           Regulatory Bodies
The American Dental Association, the
US National Cancer Society , and the
US FDA maintain that epidemiological        EXPANDED USES OF
studies have not established an               MOUTHRINSES
association between the use of alcohol
         g
containing mouthrinses and oral
cancer.
cancer.
 Most recently, in 2009, the British
Dental Health Foundation ,the British
Dental Association & International
Academy of Periodontology found no
                      alcohol-
proven links between alcohol-
containing mouthwashes and increased
incidence of oral cancer.




 ANTI-CANDIDA EFFECTS OF
 ANTI-
       MOUTHRINSES
 CHLORHEXIDINE
 LISTERINE
 CEPACOL,SCOPE




                                                                        11
                                         Mucositis
                               Immunosuppression/chemother
                               Immunosuppression/chemother
                               apy-
                               apy-40% of all patients who
                               receive this therapy
                               80% of all children who receive
                               therapy
                               Of 1.2 million annually diagnosed
                               cancer patients (US), 400,000
                               will develop mucositis
                               Apthous ulcers included in this
                               group




 Agents affecting Mucosa
                                 IRRIGATION WITH
NSAID’S                         CHEMOTHERAPEUTIC
             xerostomia-
Meds causing xerostomia-over
400                                  AGENTS
Cancer chemotherapy
C       h    th
Radiation




                                                                   12
Cutler et al, 1999 - Conclusions                               How deep can chemicals
                                                              agents penetrate a pocket?
The use of daily water irrigation:
                                                                Toothpaste                         2mm
Significant reductions in the “pro-inflammatory” levels or
IL 1β
IL-1β
And PGE2
                                                                Mouth Rinse                        1mm

Increased levels of the “anti-inflammatory” cytokine, IL-10     Irrigation           3mm (Supragingl)
                                                                                     6-7mm (Subging tip)
No change in IFNy levels




  IRRIGATION WITH LISTERINE
                                                                      IRRIGATION FACTS
                                                              • Allows patient to reduce microflora at
 REDUCED PLAQUE                                                 specific sites
                                                              • Common irrigants are water, Listerine,
                                                                Peridex, Periogard, etc
 REDUCED BLEEDING UP TO 3 WEEKS                               • Evidence for value of in office irrigation
                                                                                                    g
                                                                post SRP equivocal
                                                                     short-
                                                              • Few short-term studies show benefit in
                                                                periodontitis
 REDUCED PATHOGENS                                            • One six months study shows value of
                                                                irrigation others are short term
                                                              • Water pik is the only irrigator accepted by
                                                                ADA allowed to claim reduction in
                                                                gingivitis and associated bacteria




            IRRIGATION FACTS                                    Reduction of Bacteria in “Backspray”

                                                              Study                      Aerosol Reduction
                                                                                         Mouthrinse Water
     Strong data for effect on                                Mohammed, et al 1964          76%       35%
     gingivits
     Weak data for effect on                                  Litsky & Litsky 1970           89%         10%
     periodontitis
                                                              Rosen, et al 1983             73%          24%
     Strong data to support
     reduction of microflora when                             Fine (1991-10)                 94%
     applied subgingivally
                                                              Fine (1992-40)                 93%




                                                                                                               13
      Effect of Pre-procedural Subgingival
                    Irrigation                                             Listerine as a Post
         With Antiseptic Mouthrinse on
                   Bacteremia                                                Surgical Rinse
       Resulting From Ultrasonic Scaling                               Reduces plaque
                               Percent Reduction in                    significantly up to 7
                                                                       days post surgery
                                                                          y p         g y
                               Bacteremia Using Listerine*
Aerobic counts                      83.6% 10.9%
                                    83 6% ± 10 9%
Anaerobic counts                     89.2% ± 8.3%                      Significantly improves
Change in blood borne counts from baseline scaling to pre-procedural
irrigation and scaling
                                                                       wound healing up to 7
                                                                       days post surgery
Comparison : Listerine to Hydroalcohol Control rinse




     Chlorhexidine as a Post
         Surgical Rinse                                                               BLEACHING
    Significantly reduces                                                              AGENTS
    plaque for up to 28 days
    post surgery
    Significantly improves                                             6% - 30%                     Hydrogen
    wound healing for up to 28                                                                         Peroxide
                                                                       10%-30%
                                                                       10%-
    days post surgery                                                                             Carbamide
                                                                                                  Peroxide




   ADA Guidelines-Whitening/Bleaching
       Guidelines-                                                         ADA ACCEPTED AT HOME
                Agents                                                          BLEACHING*

  2 independent clinical studies                                           Colgate Platinum Professional
  2-6 weeks, 3 & 6 months post treatment                                   Whitening
  start
                                                                           Nite White Classic Whitening Gel
             data-
  Laboratory data-enamel & restoration
  effects                                                                  Opalesence Whitening Gel
  Release Kinetics
  Toxicology including mutagenicity
  testing
                                                                       *   Dentist dispensed, see www.ada.org for update


   Biologic response of pulp unclear




                                                                                                                           14
             ADA ACCEPTED WHITENING                                                    Office Dispensed Bleaching
                   DENTIFRICES                                                            Agents-
                                                                                          Agents-ADA Accepted
    Colgate Tartar Control Plus
    Whitening Gel
    Colgate Total Plus Whitening Gel,
    toothpaste & liquid gel                                                           p                  g
                                                                                     Opalescence Whitening Gel 10%
    Crest Extra Whitening Tartar
    protection, Crest Multicare Whiten
          Pro-
    Crest Pro-Health Whitening
    dentifrice




                                                                                     Tooth Whitening Bleaching
                                                                                          Considerations
                                                                                     Abrasitivity
                                                                                     Stain removal
                                                                                     Whitening ability
                                                                                     Tooth sensitivity
                                                                                     Soft tissue effects
                                                                                     Calculus effects




               Periodontal Breakdown Cascade                                           Periodontal Pathogens
 SRP
                          PGE                                     Pocket
                                                                                     Associated with Progressive
                     IL-1b,IL-6    Osteoclast
                                                  Bone
                                                Resorption
                                                                 Formation

                                                                   Loss of
                                                                                              Disease
Bacterial
                                                                 Attachment
Products
                                MMP’S           Connective
                                                  Tissue        Tooth Mobility     Very Strong             Strong
                                                Breakdown           Tooth
             Host Cells                                             Loss

                                                                                    Actinobacillus         T.
                                                                                                           T Forsythensis
                                                                                 (Aggregatibacter)
                                                                                   actinomycetemcomitans
                                                                                                           P. Intermedia
 Bacterial
                          Host Response component            Clinical Sequelae
Component
                                                                                   P Gingivalis
                                                                                                           T. Denticola




                                                                                                                            15
                                         PRINCIPLES OF NON-SURGICAL
                                                  THERAPY


                                        10-12 minutes per tooth with anesthesia
                                        More effective on single rooted teeth
                                        Antibiotics may be useful adjuncts
                                        Re-evaluate in six-eight weeks




   Non-surgical treatment of                      Cetacaine
     Periodontal Disease                Benzocaine 14%, Butamben 2%,
                                        Tetracaine 2%
Good oral hygiene

Scaling and root planning                      subgingivally
                                        Placed subgingivally, rapid acting

Systemic antibiotics- “special cases”   Made by Cetylite Industries

Locally delivered medications
                                        Cost less than similar products
Systemic medications non-antibiotics




      PRINCIPLES OF SURGICAL
            THERAPY


Provide access to root surface
Provide access to osseous defects
More often on posterior teeth
Usually for pockets> 5mm




                                                                                  16
                                                     PERIODONTITIS: IMPACT
                                                      ON IMPLANT SUCCESS




     REASONS FOR IMPLANT
           FAILURE
                                                       Past history of periodontitis
     Infection
                                                     represents a risk factor for peri-
     bone quality
     smoking                                          implantitis(esp. diabetics and
     surgical trauma                                                 k
                                                                 smokers) )
     systemic disease
     medications
     overload
                                                               Van der Weijden ‘05
     periodontitis history
     genetics?




                                                          Patients with local
Patients with history of periodontitis can           inflammation or inadequate
maintain healthy tissue around implants               oral hygiene should not be
                                                     subjected to dental implant
                                                                therapy

             Baelum & Ellegaard ’04, Karoussis ‘04
                                                                   Buser ‘99




                                                                                          17
                                                                        Bacterial
    In partially edentulous                                           Recolonization
 patients, micro-organisms in                                  Following implant placement, bacteria
periodontal pockets may serve                                  begin to immediately recolonize
as a reservoir for colonization                                surfaces
of the subgingival area around                                 Complex microflora is established
           implants                                            within one week after abutment
                                                               connection
                                                               Healthy implants present with low
                                                               biofilm scores
        Meffert ’93,Nevins ’01, Mombelli ’02, Quirynen ‘02
                                                               Unhealthy implants present with high
                                                               biofilm scores




     Periodontal Pathogens
   Associated with Progressive
            Disease                                           Patients with local inflammation or
  Very Strong                                                inadequate oral hygiene should not
                                     Strong
                                     T. forsythensis
                                            y
                                                                be subjected to dental implant
  Aggregatibacter
  actinomycetemcomitans                                                     th
                                                                            therapy
                                     P. intermedia
  P. gingivalis

                                     T. denticola                             Buser ‘99




                                                                 Medications: Impact on
                                                                   Implant Success

        Another Reason for
                                                                Agents causing xerostomia increase
                                                                accumulation of biofilm
        Implant Failure
          p                                                     Calcium Channel blockers may increase
                                                                soft tissue enlargement
                                                                Some herbal products increase soft
              Adverse effects on implant                        tissue bleeding and impair healing
               subgingival surface from                         response
             treatment for peri-implantitis                     Bisphosphonates may increase failure
                                                                rate, especially IV Administration




                                                                                                        18
  Perio - Chemotherapeutics               Periodontal disease is an
                                                 Infection
                                          Bacteria in crevice
     Mechanical Methods
                                          Bacteria in epithelium in ANUG
                         Plus
                                          Bacteria in epithelium, connective
                                          tissue and bone in periodontitis
        Chemical Agents




    Antibiotics and                      Localized Aggressive
  Periodontal Therapy                    Periodontitis
Tetracyclines
  LAP, GAP, severe adult cases
 ug e t
Augmentin                                         y y
                                               Doxycycline             g
                                                                   100mg.
  Refractory, LAP
Metronidazole
 Severe adult cases                                      #21
Amoxicillin + Metronidazole, Augmentin
 + Metronidazole                                     1 BID Day 1
 LAP,GAP,Refractory
Clindamycin                                        1 daily to finish
 LAP, Refractory




     Localized Aggressive                Generalized Aggressive
        Periodontitis                    Periodontitis
 Amoxicillin plus Metronidazole
   Amoxicillin-500mg
   Amoxicillin 500mg TID
       #30
   Metronidazole-250mg TID                      Clindamycin 150mg.
       #30
                                                      #30-36
                                                           1 TID




                                                                               19
Pseudomenbranous Colitis                         Refractory Periodontis
Caused by overgrowth of C. difficle
Incidence                                        Improper Diagnosis/treatment
   *31% Cephalosporins
    31%                                          Bacterial Invasion into tissue
   *27% Ampicillin                               Systemic Factors
   *11% Clindamycin                              Medication Factors
   * 31% Miscillaneous Antibiotics




 Drug Interaction-Birth
     Control Pills                                 HOST MODULATION
The “protective effect” of birth control pills           THE 21ST CENTURY
can be lost when broad spectrum
antibiotics are administered
         it tl
concomitantly.

Patients should be advised to use other
methods of contraception during
medication with antibiotics and for 2
weeks post antibiotics usage!




                                                    Pathological Tissue
                                                        Destruction
                                                   INFILTRATING CELLS           Bacterial             RESIDENT
                                                                                 Toxins                 CELLS

                                                                              Pro-Inflammatory
                                                                                  Cell / Cell
                                                                                 Messengers
                                                                                 (Cytokines)




                                                                WHITE CELLS




                                                           Enzymes                                Enzymes
                                                          Gelatinase                             Collagenase




                                                                                                         CONNECTIVE
                                                                                                         TISSUE
                                                                       TISSUE DESTRUCTION




                                                                                                                      20
                        Doxycycline Plasma
                      Concentrations - Steady-
                              State                                                                                                                                                                                Conclusion-Periostat FDA Studies
                                                                                                                                                                                                            A 9-month course of SDD treatment results in
                                                                                                                                                                        20mg QD
                                Do xycycline con cen tratio n (ng /m L )




                                                                           1400                                                                                         20mg BID
                                                                           1200                                                                                         50mg QD                                  -Gain in attachment level beyond SRP
                                                                           1000                                                                                      Minimum anti-microbial level                -Reduction in probing depth beyond SRP
                                                                            800                                                                                                                                  -30% of sites reduced probing depth by 2mm or more
                                                                            600                                                                                                                                  -Reduction in Bleeding on probing
                                                                            400                                                                                                                                  -Side effects similar to SRP
                                                                            200
                                                                              0
                                                                                  0     2     4   6      8     10    12     14     16    18     20    22     24

                                                                                                                    Hours




                            Summary: Microbiological
                            Data on Long Term Use of
                                   Periostat®                                                                                                                                                               Periostat® Phase IV Study
No changes in antimicrobial susceptibility
(up to 18 months)                                                                                                                                                                                            Repeat Sub-Gingival
                                                                                                             Thomas, J et al. J Periodontol 71(9):1472-1483, 2000.                                          Debridement in Aggressive
No antibacterial effect on the subgingival                                                                                                                                                                  (Severe Generalized)
microflora associated with adult                                                                                                                                                                            Periodontitis
periodontitis
                                                                                                               Walker,C et al. J Periodontol 71(9):1465-1471, 2000.
                                                                                                                                                                                                                  Novak et al, University of Pittsburgh Dental School
No effect on the microflora of the GI tract,
the GU tract or the skin                                                                                                                                                                                                      Novak, J et al: Adjunctive subantimicrobial dose doxycycline in the management of severe periodontitis.
                                                                                                                                                                                                                              J Dent Res 81(Spec Issue A; Abstract #4072):A-498, 2002

                                                                                                               Walker,C et al. J Dent Res., IADR Abstracts 2001




                                                                                  Mean PD Change                                                                                                              % Tooth Sites with PD Increase
                                                                                             Periostat Phase IV Study                                                                                                     >2mm
                                                                                                                                                                                                                            Periostat Phase IV Study
                                                                                  Baseline PD - > 7mm                          Non-molar teeth only                                                                                              All Sites

                                                                                                                                                                    Periostat            n = 10
                       4                                                                                                                                                                                           2
                                                                                                                                                                    Placebo              n = 10
Mean PD Change (mm)




                      3.5
                       3                                                                              3 16
                                                                                                      3.16                                      3.2                                                               1.5
                                                                                                                           3.07
                      2.5                                                                                                                                                                                                                                                                                      Placebo n = 1475
                                                                                                                                                                                                                                                                                                               Periostat n = 1608
                       2                                                              2.36                                                                                                                         1
                                                                                                      1.96                 2.02                1.98
                      1.5
                                                                                                                                                                                                                  0.5
                       1                                                              1.27

                      0.5
                                                                                                                                                                                                                   0
                       0
                            0                                                     1 month          3 months          5.25 months           8 months                                                                     1 month       3 months                  5.25                 8 months
                                                                                                                                                                                                                                                               months
                                                                                                  Novak, J et al: Adjunctive subantimicrobial dose doxycycline in the management of severe periodontitis.
                                                                                                                                                                                                                                        Novak, J et al: Adjunctive subantimicrobial dose doxycycline in the management of severe periodontitis.
                                                                                                  J Dent Res 81(Spec Issue A; Abstract #4072):A-498, 2002
                                                                                                                                                                                                                                        J Dent Res 81(Spec Issue A; Abstract #4072):A-498, 2002




                                                                                                                                                                                                                                                                                                                                                  21
# Tooth Sites Gaining >3mm CAL
                   Periostat Phase IV Study                                                                                            Periostat Diabetes
                                                                                                                                             Study
                      Baseline PD > 7mm
                                                                                                                                  20 patients completed-3 mos.
 100
  90                                                                                                                              PD decrease 1.7mm over SRP
  80
  70                                                                                                                                              1.6mm
                                                                                                                                  CAL increased 1 6mm over SRP
  60                                                                                        Placebo n = 175
  50                                                                                        Periostat n = 237
                                                                                                                                  HbA1c levels, ROS, cyokines (mmp8)
  40                                                                                                                              sig. better than SRP
  30
  20                                                                                                                              Expanded to 400 patient study with
  10
                                                                                                                                  similar results
   0
         1 month     3 months          5.25 months                8 months
                        Novak, J et al: Adjunctive subantimicrobial dose doxycycline in the management of severe periodontitis.
                        J Dent Res 81(Spec Issue A; Abstract #4072):A-498, 2002




             Periostat & Atridox
               PD/AL (N=151)                                                                                                            Periostat-ADA Seal
                    3mos                                        6mos                                                                                 “Periostat® has been
                                                                                                                                                    shown to help stop the
Shallow
                                                                                                                                                    progression of
Pockets                                                                                                                                             periodontitis when
46
4-6mm 1.5mm                      1.5mm                      1.7mm                       1.6mm                                                       used as directed as an
        (0.9)                    (0.9)                      (1.2)                       (1.2)                                                       adjunct to scaling and
                                                                                                                                                    root planing, in a
                                                                                                                                                    conscientiously applied
Deep                                                                                                                                                program of oral hygiene
Pockets 2.2mm                    2.0mm                      2.5mm                       2.2mm                                                       and regular
7mm     (1.5)                    (1.3)                      (1.7)                       (1.5)                                                       professional care.”
or>




       Rx                                                                                                                         Rx
          Doxycycline 20 mg.                                                                                                      Doxycycline      100mg
                                                                                                                                      #45 tabs
                                Disp: 180 t b
                                Di        tabs
                                 SIG: 1 tab bid                                                                                        ¼ tab BID
       refills 2




                                                                                                                                                                              22
                                    Locally Delivered
                                      Medications
                               Perio Chip (Chlorhexidine)
                               Atridox (Doxycycline)
                                       (     y     )
                               Arestin (Minocycline)
                               NSAID’s ?




“Evaluation of Actisite                  PERIO CHIP
  Tetracycline Fibers
Around Ailing Implants”



Koutsonikos, Yukna, Naser, &
           Mayer




                                                            23
                                                      Mean Data-Pocket Depth Reduction
                                                                                        Change from Baseline
                                                             0.0
                                                                                                                        Oral Hygiene
                                                            -0.2
                                                                                                                        Vehicle




                                                Mean (mm)
                                                            -0.4                                                        SRP
                                                                                                                        ATRIDOX™
                                                            -0 6
                                                            -0.6

                                                            -0.8

                                                            -1.0

                                                            -1.2

                                                            -1.4
                                                                                   2               4                6                  9
                                                                                                       Months
                                                            Garrett, Steven et al. J Periodontol 1999;70:490-503.




              ARESTIN                                                                     How to Use



                                                            Depress Handle to
                                                            Express Arestin
                                                            from the Cartridge




   Product Comparisons:
 Change (mm) from Control
       at Study End
     Periostat Actisite Perio Atridox Arestin
                        Chip

PD   O.48     O.73     O.4O O.60      O.35
     (0.3)

CAL 0.38                     O.50
    (0.17)




                                                                                                                                           24
                        ADA/PDR Guide to Dental Therapeutics

                                   800 947 4746


                             Biological Therapies in Dentistry
                                      800 568 7281
                                        BTD SO9




New Dimensions in
Periodontal Therapy


   Todays Research is
   Tomorrow’s Promise




                                                                 25

				
DOCUMENT INFO