Local Drug Delivery

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




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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




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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




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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




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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)




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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




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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




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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




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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




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Documents

Local Drug Delivery