CHEMICAL

PERIODONTAL
THERAPY
 Chemical Periodontal Therapy
Antimicrobial agents;
- Antiseptics Can be used:
topically, locally
- Antibiotics applied &
systemically

Miscellaneous agents;
- Matrix protein
- Growth factor
- Hydrogen peroxide
 Chemical Periodontal Therapy
Any antimicrobial use is ADJUCT to mechanical
therapy.

Antimicrobial used in periodontal therapy can

be divided in 2 groups:
- Directed against supra-gingival plaque
development
- Directed against sub-gingival bacteria
 Chemical Periodontal Therapy
Periodontitis can be classified by:

• Disease activity (chronic/aggressive)

• Cause (specific bacterial, fungal / viral infection)
• Site (localized or generalized)
• Extent (size & morphology defects)
• Type of associated gingivitis (chronic/necrotizing)
• Type of patient (child, adolescent, adult/ compromised)

Non-specific plaque theory (reduction of bacterial load)

Specific plaque theory (specific plaque therapy)

 Chemical Periodontal Therapy
ANTIBIOTICS

1. Use of antibiotics (systemically / local application) mainly directed

against specific bacteria & sub-gingival plaque to target identified
periodontal pathogens. Eg. In ANUG & localized aggressive
periodontitis.

2. Antibiotics is directed against specific microorganisms, eg. Aa in

specific plaque hypothesis in ANUG/P & aggressive periodontitis.

3. While mechanical removal of plaque aimed at reduction of bacterial

load for non-specific plaque theory.
 Chemical Periodontal Therapy
ANTIBIOTICS

4. If unresponsive pockets (after reassessment therapy done

& no response to therapy), chlorhexidine in slow release of
polymer can be used locally, advantage of that, agents can
be sustained release within the pocket. Locally applied
antibiotics also can be used in this situation.

5. Used of antibiotics in periodontal abscess usually not

necessary if the abscess only localized unless there are
signs of spread of infection to systemic area / sign of
cellulitis/ lymphadenopathy.
 Chemical Periodontal Therapy
ANTIBIOTICS

6. Post surgical rinsing with chlorhexidine

mouthwash mainly due to inability to
mechanically removed plaque because
discomfort.

7. Post surgical systemic antibiotic prescription may

not indicated, unless complex surgical
procedures been carried out (post-implant
surgery) / patient is medically compromised.
 Chemical Periodontal Therapy
ANTIBIOTICS

8. Indication of use of antimicrobial agents to patient

with lack of manual dexterity or with patients with
mental disability is clear.

9. Patient wearing orthodontics appliances cannot

used chlorhexidine mouthwash for a long term due
to tooth & tongue staining side effects.
 Chemical Periodontal Therapy
Antibiotics agents:

 Local application
 Systemic use
 Chemical Periodontal Therapy
Antibiotics – Local Application

Antibiotics can be in form of:

Gel – for topical application onto surface or
sub-gingival application.
May present in polymer.
Also present in the form of biodegradable
slow, release gel, hollow or solid fibers.
 Chemical Periodontal Therapy
Antibiotics – Local Application

Examples:
a. Elyzol gel - 25% of metronidazole
b. Dentomycin gel - 2% of minocycline
c. Actisite – tetracycline fibers (hollow/solid)
d. Periocline - 2% minocycline
e. Atridox - 42.5 mg doxycycline
f. Arestin - 1 mg minocycline
 Chemical Periodontal Therapy
Antibiotics – Systemic Uses

• In the form of liquid, tablets or capsules –

suitable if patients diagnosed with aggressive
periodontitis ONLY.
• Must finish antibiotic simultaneously with the
therapy/ root debridement.
 Chemical Periodontal Therapy
Antibiotics – Systemic Uses (Aggressive Periodontitis )

Amoxicillin in combination with metronidazole (if allergic to

penicillin give clindamycin);

- 250 mg amoxicillin & 200 mg metronidazole tds for 4 to 7 days.

Tetracycline

- 250 mg tetracycline for 14 days

- Doxycycline 100 mg once a day for 14 days (double dose for first
day because half of it will bind to plasma & another half will be in
blood).
 Chemical Periodontal Therapy
Antibiotics – Systemic Uses

• In case of ANUG/P, metronidazole may be needed for 3

– 4 days only.

- 200 mg metronidazole tds for 3 – 4 days.

- Analgesic may be prescribed to patient diagnosed with
ANUG/P due to pain.
- Since the ANUG/P lesions being very painful to
mechanical plaque control, chlorhexidine may be
given.
 Chemical Periodontal Therapy
Antibiotics – Systemic Uses

• For post-surgical systemic antibiotic,

metronidazole may be needed for 1 – 7 days.

- 400 mg metronidazole tds for 1 day.

- Analgesic may also prescribed.
- Chlorhexidine mouthwashes must be given since
the wound may be painful to mechanical plaque
removal.
 Chemical Periodontal Therapy
Antibiotics – Systemic Uses

• Periostat® is available as a

- 20 mg doxycycline taken twice daily about an hour before

or 2 hours after meals.
- Adjunct to scaling & root planning.
- Act as collagenase inhibitor (degrade collagen at
periodontal ligament/gingiva but not to controlled the
bacteria) at low concentration.
- Danger to develop bacterial resistance.
- Take about a month.
 Chemical Periodontal Therapy
Indications
Chlorexidine mouthwash indicated to post-surgical to reduce
the bacterial load or to prevent plaque formation at the time
when mechanical cleaning difficult due discomfort.

Patient with mental & physically disabilities lack manual

dexterity. Examples:
- Parkinson disease
- Adjuct to immunocompromised patient (HIV/AIDS)
- Cerebral palsy
 Chemical Periodontal Therapy
Indications

In cases like refractory periodontitis (due to smoking), as an

adjunct instrumentation, locally applied antimicrobial agents
can be used.

Antibiotic prophylactic agents in which the risks of bacterimia

& infective endocarditis is high.
 Chemical Periodontal Therapy
Indications

Systemic antibiotics prescribed are directed against specific

microorganisms as an adjunct to mechanical instrumentation
in aggressive periodontitis & ANUG/P.

The used of systemic antibiotic without cautions can lead to

development of bacterial resistance.

Certain individual may suffered from immediate

hypersensitivity which can be fatal.
 Chemical Periodontal Therapy
ANTISEPTICS

• Topically (mothwashes)
- Oradex – chlorhexidine 0.12%
- Listerine® antiseptic mouthwash (phenolic
compound/ essential oil)
- Plax® (triclosan)

Typically act supra-gingivaly.

 Chemical Periodontal Therapy
ANTISEPTICS – Mouthwashes

• Quaternary ammonium compound (cetylpyridium chloride)

• Hexidine – Bactidol®
• Oxygenating agents – hydrogen peroxide
• Amine alcohols – Delminol
• Povidone iodine natural products – sanguinarines

 All these available either as mouthwashes, irrigation,

toothpaste, gel/ spray.
 Chemical Periodontal Therapy
ANTISEPTICS

• Locally applied

- Slow release devices (biodegradable polymer, gel, fibers,

collagen)
- Applied into periodontal pockets:
Perio Chip® (2.5 mg chloroxedine in gelatin matrix)
Atrigel® (5% sanguinarine)

 Typically act sub-gingivally.

 Chemical Periodontal Therapy
ANTISEPTICS – Chlorhexidine

• Bisguanide compound
• Dicationic and strong base
• Prolonged action
• Concentration – 0.2% or equivalent
• The only product to kill bacteria
• Not act as anti-adhesive
• Only can penetrate into thin plaque not thick /mature (calculus) plaque.
• Can inhibit the plaque formation but cannot eliminate the plaque in
untreated mouth.