Dr.

Larry Wolff
Periodontology III
Spring Semester, 2009
School of Dentistry
University of Minnesota

Local Delivery of
Antimicrobials

Use of Local Delivery

and Systemic
Antimicrobials in
Periodontal Therapy

Questions on Local Delivery

Questions on Local
Delivery

What are best drugs?

What are best delivery systems?
How often apply drug?
What is duration of results?

Which diseases can be treated?

Adjunct or alternate to SC/RP?
Antibiotic resistant bacteria?
Is local as effective as systemic
delivery?

Site Specific
Antimicrobial Therapy

Local Vs. Systemic Drug Delivery

Advantage - Local
More concentration
Fewer side effects
Sustained delivery
Patient compliance

Advantages
Disadvantages
Types
Clinical Indications

Disadvantage - Local
More chairside time
More expensive
No effect on
bacterial reservoirs

PerioChip Chlorhexidine
Doxycycline
Atridox
Minocycline
Arestin

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Dr. Larry Wolff

Periodontology III
Spring Semester, 2009
School of Dentistry
University of Minnesota

Actisite

Fiber after
10 days

Tetracycline Hydrochloride
(Periodontal Fiber Therapy)
Tissue
distension
following
fiber removal

Actisite Fiber Clinical Trial

Probing Depth Reduction (mm)
Time (mo)

SC/RP

1.0

SC/RP +
Fiber
1.3

1.1

1.7

Comparison - Tetracycline

PerioChip

Chlorhexidine - 2.5 mg
Gelatin is carrier
Bioabsorbable
Broad spectrum
Pockets > 5 mm
Decreases pockets
No refrigeration

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Systemic
250 mg/tablet
Four times/day
Ten days
Total: 10,000 mg
Concentration 4-8
g/ml

Local
12.5 mg/fiber
Ten Days
Total: 12.5 mg
Concentration
>1500 g/ml

Dr. Larry Wolff

Periodontology III
Spring Semester, 2009
School of Dentistry
University of Minnesota

PerioChip
Patient Information
Mild to moderate sensitivity
normal during first week
Continue toothbrushing
Avoid flossing site for 10 days
Continue regular diet

PerioChip Clinical Trial

Atridox

Treatment of periodontal pockets

with PerioChip as an adjunct to
SRP provided a significantly
greater improvement in clinical
parameters than SRP alone.

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Doxycycline - 8.5%
Bioabsorbable
Controlled release - 7 days
Antibacterial
Pockets > 5 mm
Decreases pockets
Increase CAL

Dr. Larry Wolff

Periodontology III
Spring Semester, 2009
School of Dentistry
University of Minnesota

Indications of Atridox

Atridox

For use in the treatment of

chronic periodontitis; for a gain
in clinical attachment, reduction
in probing depth and reduction
in bleeding on probing

Subgingival controlled release product

Two syringe mixing system
Syringe A 450 mg Atrigel
Syringe B 50 mg Doxycycline

Atridox Setting Process

Upon contact with crevicular fluid, the
liquid product solidifies and then allows for
controlled release of drug for a period of 7
days
Sets to a wax-like consistency in 1-2
minutes

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Dr. Larry Wolff

Periodontology III
Spring Semester, 2009
School of Dentistry
University of Minnesota

Atridox Vs SC/RP %
Change > 2 mm

4 months

Atridox

Doxycycline treatment
significantly reduced the
anaerobic bacteria but did not
result in development of
antibiotic resistant bacteria

9 months

Root Planing

Walker JP 2000

Minocycline Powder

Micocycline
Microspheres
Cartridge

Dispenser &
Handle

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Dr. Larry Wolff

Periodontology III
Spring Semester, 2009
School of Dentistry
University of Minnesota

Minocycline Microspheres
Preliminary Findings

Metronidazole Local Delivery

Minocycline Microsphere treated group had

significantly greater pocket depth reduction
compared to SRP alone.
25% more patients in the microsphere group
shifted from mean PD > 6 mm at baseline to
< 5 mm at month 9.

Biodegradable
Anaerobic bacteria
Bactericidal
25% Metronidazole
> 5 mm PD

Concentration of Metronidazole
in GCF (g/ml)
500
400
300
200
30
20
10
0

12

Time (Hours)

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24

36

Dr. Larry Wolff

Periodontology III
Spring Semester, 2009
School of Dentistry
University of Minnesota

Metronidazole Local
Delivery

Indications for
Controlled
Antimicrobial
Delivery

Metronidazole + Root
Planing not consistently
shown more effective
than root planing alone.

Controlled Drug
Delivery

Non-Responding
to SC/RP
PD > 5 mm

Pockets > 5 mm
Bleeding on Probing

Where Esthetics is a
Concern and Surgery
May be Contraindicated

Refractory
Periodontitis

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Dr. Larry Wolff

Periodontology III
Spring Semester, 2009
School of Dentistry
University of Minnesota

Medically
Compromised Patients

Indications for Local Delivery

(Periodontal Surgery
Contraindicated)
Indications
for local
delivery

Recent Oral
Cancer Age 80

Patients Who
Smoke

Dental
Phobic
Patient

Indications
for local
delivery

Periostat

Summary: Locally Delivered Drugs

Actisite

Atridox Periochip
Easy

Easy

Only FDA approved oral,

systemic treatment for chronic
periodontitis that suppresses
activity of tissue destroying
enzymes

Arestin

Ease of use

Moderate

# of sites

Multiple

8 - 15

1-2
teeth/fiber

Sites/syringe

1 chip/site

1 site/cartridge

Dressing/glue

Yes

Yes/No

No

No

GCF Conc
ug/ml
Release (days)

1300

1000

125

1000

10

10

10

Removal

Yes

No

No

No

Uncontrolled
Diabetes

Easy

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Dr. Larry Wolff

Periodontology III
Spring Semester, 2009
School of Dentistry
University of Minnesota

Periostat - Prescribing
Information

Periostat Indication
For use as an adjunct to
scaling and root planing to
promote attachment level gain
and to reduce pocket depth in
patients with chronic
periodontitis.

Periostat 20 mg doxycycline
Dosage one 20 mg capsule 2x/day
Duration of Therapy clinicians judgment
Efficacy minimum - 3 months
maximum - 9 months
Safety 12 months - follow traditional
tetracycline contraindications

Periostat - General Patient

Instructions

Periostat/RP vs RP
% Change > 2 mm

One capsule in the AM, one in the PM

Take one hour before meals
Take with adequate fluids
Missed dose? Dont double-up
Rx: Periostat
Disp: 180 capsules
Sig: 1 cap BID
Refills: 2

Periostat - Acts as an
Enzyme Suppressor

Indications

Studies show that

doxycycline hyclate 20
mg bid has no
antimicrobial action
No change in bacterial
flora after 18 months
No induction of resistance
after 18 mos

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Dr. Larry Wolff

Periodontology III
Spring Semester, 2009
School of Dentistry
University of Minnesota

Maintenance
Patients

Patients with
Refractory/Recurrent
Periodontitis

Oral Manifestations of
Uncontrolled Diabetes Mellitus
Severe gingival inflammation
Acute gingival or periodontal abscesses
Rapidly advancing periodontal disease

Smokers trying to quit

Preserve
natural
teeth

Professional Cost
Arestin

$15/cartridge

1 tooth

1 minute

Atridox

$60/syringe

6 teeth

10 minutes

Periochip

$16/chip

1 tooth

1 minute

Periostat

$60/month

All teeth

30 seconds

Insurance Codes
04381
01330
04999
01110
04355
04341
04355
04910

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Local drug delivery

Oral hygiene instruction
Re-evaluation
Adult prophylaxis
Prophylaxis - gross cleaning
Periodontal scaling/root planing
Full mouth debridement
Periodontal maintenance