local drug delivery
DESCRIPTION
LOCAL DEUG DELIVERY DENTISTRYTRANSCRIPT
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Use of Local Deliveryand Systemic
Antimicrobials inPeriodontal Therapy
Local Delivery ofAntimicrobials
Advantages
Disadvantages
Types
Clinical Indications
Questions on Local Delivery
What are best drugs?
What are best delivery systems?
How often apply drug?
What is duration of results?
Questions on LocalDelivery
Which diseases can be treated?
Adjunct or alternate to SC/RP?
Antibiotic resistant bacteria?
Is local as effective as systemicdelivery?
Local Vs. Systemic Drug Delivery
Advantage - Local
More concentration
Fewer side effects
Sustained delivery
Patient compliance
Disadvantage - Local
More chairside time
More expensive
No effect onbacterial reservoirs
Site SpecificAntimicrobial Therapy
PerioChip
Atridox
Arestin
Chlorhexidine
Doxycycline
Minocycline
Dr. Larry WolffPeriodontology III
Spring Semester, 2009School of Dentistry
University of Minnesota
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ActisiteTetracycline Hydrochloride
(Periodontal Fiber Therapy)
Fiber after10 days
Tissuedistensionfollowingfiber removal
Actisite Fiber Clinical TrialProbing Depth Reduction (mm)
1.71.16
1.31.03
SC/RP +Fiber
SC/RPTime (mo)
Comparison - TetracyclineSystemic
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
PerioChip Chlorhexidine - 2.5 mg Gelatin is carrier Bioabsorbable Broad spectrum Pockets > 5 mm Decreases pockets No refrigeration
Dr. Larry WolffPeriodontology III
Spring Semester, 2009School of Dentistry
University of Minnesota
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PerioChipPatient Information
Mild to moderate sensitivitynormal during first week
Continue toothbrushing
Avoid flossing site for 10 days
Continue regular diet
PerioChip Clinical Trial
Treatment of periodontal pocketswith PerioChip as an adjunct to
SRP provided a significantlygreater improvement in clinical
parameters than SRP alone.
Atridox Doxycycline - 8.5%
Bioabsorbable
Controlled release - 7 days
Antibacterial
Pockets > 5 mm
Decreases pockets
Increase CAL
Dr. Larry WolffPeriodontology III
Spring Semester, 2009School of Dentistry
University of Minnesota
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Indications of AtridoxFor use in the treatment of
chronic periodontitis; for a gainin clinical attachment, reductionin probing depth and reduction
in bleeding on probing
Atridox 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 forcontrolled release of drug for a period of 7days
Sets to a wax-like consistency in 1-2minutes
Dr. Larry WolffPeriodontology III
Spring Semester, 2009School of Dentistry
University of Minnesota
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Atridox Vs SC/RP %Change > 2 mm
Atridox Root Planing4 months 9 months
Doxycycline treatmentsignificantly reduced the
anaerobic bacteria but did notresult in development of
antibiotic resistant bacteria
Walker JP 2000
Minocycline Powder MicocyclineMicrospheres
Cartridge
Dispenser &Handle
Dr. Larry WolffPeriodontology III
Spring Semester, 2009School of Dentistry
University of Minnesota
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Minocycline MicrospheresPreliminary Findings
Minocycline Microsphere treated group hadsignificantly greater pocket depth reductioncompared to SRP alone.
25% more patients in the microsphere groupshifted from mean PD > 6 mm at baseline to< 5 mm at month 9.
Metronidazole Local Delivery
Biodegradable Anaerobic bacteria Bactericidal 25% Metronidazole > 5 mm PD
Concentration of Metronidazolein GCF (g/ml)
500
400
300
200
30
20
10
0
0 4 8 12 24 36
Time (Hours)
Dr. Larry WolffPeriodontology III
Spring Semester, 2009School of Dentistry
University of Minnesota
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Metronidazole LocalDelivery
Metronidazole + RootPlaning not consistentlyshown more effective
than root planing alone.
Indications forControlled
AntimicrobialDelivery
Controlled DrugDelivery
Pockets > 5 mm
Bleeding on Probing
Non-Respondingto SC/RP
PD > 5 mm
Where Esthetics is aConcern and Surgery
May be Contraindicated
RefractoryPeriodontitis
Dr. Larry WolffPeriodontology III
Spring Semester, 2009School of Dentistry
University of Minnesota
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MedicallyCompromised Patients
(Periodontal SurgeryContraindicated)
Indicationsfor localdelivery Uncontrolled
DiabetesRecent Oral
Cancer Age 80
Indications for Local Delivery
Patients WhoSmoke
Indicationsfor localdelivery
DentalPhobicPatient
Summary: Locally Delivered Drugs
NoNoNoYesRemoval
1010710Release (days)
100012510001300GCF Concug/ml
NoNoYes/NoYesDressing/glue
11 site/cartridge
81 chip/site
8 - 15Sites/syringe
Multiple1-2
teeth/fiber
# of sites
EasyEasyEasyModerateEase of use
ArestinPeriochipAtridoxActisite
PeriostatOnly FDA approved oral,systemic treatment for chronicperiodontitis that suppressesactivity of tissue destroyingenzymes
Dr. Larry WolffPeriodontology III
Spring Semester, 2009School of Dentistry
University of Minnesota
8 of 10
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Periostat IndicationFor use as an adjunct to
scaling and root planing topromote attachment level gainand to reduce pocket depth in
patients with chronicperiodontitis.
Periostat - PrescribingInformation
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 PatientInstructions
One capsule in the AM, one in the PM
Take one hour before meals
Take with adequate fluids
Missed dose? Dont double-up
Rx: PeriostatDisp:180 capsulesSig: 1 cap BIDRefills: 2
Periostat/RP vs RP% Change > 2 mm
Periostat - Acts as anEnzyme Suppressor
Studies show thatdoxycycline hyclate 20mg bid has noantimicrobial action
No change in bacterialflora after 18 months
No induction of resistanceafter 18 mos
Indications
Dr. Larry WolffPeriodontology III
Spring Semester, 2009School of Dentistry
University of Minnesota
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MaintenancePatients
Patients withRefractory/Recurrent
Periodontitis
Smokers trying to quit
Oral Manifestations ofUncontrolled Diabetes Mellitus
Severe gingival inflammation
Acute gingival or periodontal abscesses
Rapidly advancing periodontal disease
Preservenaturalteeth
Professional Cost
30 secondsAll teeth$60/monthPeriostat
1 minute1 tooth$16/chipPeriochip
10 minutes6 teeth$60/syringeAtridox
1 minute1 tooth$15/cartridgeArestin
Insurance Codes04381
01330
04999
01110
04355
04341
04355
04910
Local drug delivery
Oral hygiene instruction
Re-evaluation
Adult prophylaxis
Prophylaxis - gross cleaning
Periodontal scaling/root planing
Full mouth debridement
Periodontal maintenance
Dr. Larry WolffPeriodontology III
Spring Semester, 2009School of Dentistry
University of Minnesota
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