LOCAL DRUG DELIVERY AS AN ADJUNCT TO MECHANICAL DEBRIDEMENT

1. Dr.K.SATHISH KUMAR,II YEAR MDS, GUIDE : Dr. T. RAMAKRISHNAN, DEPARTMENT OF PERIODONTICS
SEMINAR : 7

2. INTRODUCTION
 Periodontal diseases are a heterogenous group of diseases, proven to be
caused by pathologic microorganisms that organize to form a plaque
associated biofilm on the tooth surface.
 The destruction of the periodontium is a result of interaction between
microorganisms and specific host defense mechanism.

3.  Elimination or adequate suppression of putative periodontopathic
microorganisms in the subgingival microbiota is essential for periodontal
healing.
 Antimicrobial treatments in periodontics range from mechanical debridement
of tooth surfaces and home plaque removal to local and systemic delivery of
chemical antimicrobial agents.

4. HISTORY
It was Dr. Max GoodSon (1979) who championed and
developed controlled release local delivery of therapeutic agents
into a viable concept

5. ANTI
MICROBIAL
AGENTS
LOCAL
ROUTE
SYSTEMIC
ROUTE
INTESTINAL
ABSORPTION
ADVERSE
EFFECTS

6. TYPES OF LOCAL ANTIMICROBIAL AGENT
THERAPY IN PERIODONTICS –( RAMS AND SLOTS)
LOCAL DRUG
DELIVERY
Personally
applied (in patient
home self-care)
Nonsustained
subgingival drug
delivery
Sustained
subgingival drug
delivery
Professionally
applied (in dental
oflice)
Nonsustained
subgingival drug
delivery
Sustained
subgingival drug
delivery

7. Drug Delivery Devices
GREENSTEIN
Sustained and
controlled drug
release
Non sustained drug
release

8. VARIOUS DRUG DELIVERY DEVICES ARE…
■ FIBERS
■ FILM
■ INJECTABLE SYSTEMS
■ GELS
■ STRIPS AND COMPACTS
■ VESICULAR LIPOSOMAL SYSTEMS
■ MICROPARTICLE SYSTEM
■ NANOPARTICLE SYSTEM

9. INDICATIONS
 Isolated periodontal pockets (>5mm)
 Periodontal patients who are medically compromised where surgical
therapy is contraindicative.
 In combination with mechanical debridement or alone.
 Recurrent or refractory periodontitis.
 During periodontal regenerative procedures.

10. CONTRAINDICATIONS
 Hypersensitivity reaction
 Alcoholics
 Patients susceptible to infective endocarditis
 Delivery of antimicrobial agents using ultrasonic scalers is
contraindicated in asthmatics, infective conditions (AIDS, TB) and
those with cardiac pacemakers

11. DISADVANTAGES
■ Difficulty in placing into deeper parts of pockets and furcation lesions.
■ Patient compliance and manual dexterity
■ Time consuming and labour intensive in-patients with numerous
advanced lesions.
■ Non-sustained drug delivery provides only a brief exposure of the target
microorganism to the applied antimicrobial agent.

12. Efficacy Of Local Drug Delivery
Sufficient
duration of
time
Sustained
release.
Adequate
concentration
Intended site
of action.
Local route of drug delivery can attain 100-fold higher concentrations of an antimicrobial agent in
subgingival sites compared with a systemic drug regimen therebyreducing the total patient dose by
over 400 fold avoiding development of drug-resistant at non oral body sites.
-Goodson J. Antimicrobial strategies for treatment of periodontaldiseases. Periodontol 2000: 1994

13. Commercially Available Products
1. Tetracycline fibers (Actisite)
2. Metronidazole gel (Elyzol)
3. Minocycline ointment (Dentomycine)
4. Chlorhexidine Chip (Perio chip)
5. Doxycycline hyclate in a resorbable polymer
(Atridox)
6. Minocycline microspheres (Arestin).

14. TETRACYCLINE
 The first delivery devices involved hollow fibers of cellulose acetate filled
with tetracycline.

15. Tetracycline –containing fibers(Actisite)
 FDA approved
 Non resorbable, biologically inert, safe plastic copolymer (ethylene &vinyl
acetate) loaded with 25% tetracycline HCL powder packed as thread of 0.5mm
diameter &23cm length
 It maintains constant concentrations of active drug in the crevicular fluid in excess
of 1000 μg/mL for a period of 10 days.(Maurizio S et al)
 In contrast GCF conc. of only 4-8 microgram/ml were reported after systemic
administration, 250 mg qid for 10 days.

16. Subgingival doxycycline
 ATRIDOX (42.5 mg Doxycycline)
 It is the only local delivery system accepted byADA

17.  Doxycycline levels in GCF peaked to 1,500 - 2000 μg/ml in 2 hours following
treatment with ATRIDOX.
 Local levels of Doxycycline have been found to remain well above the MIC for
periodontal pathogens (6.0μg/ml) through Day 7.
 95% of the polymer is bio absorbed or expelled from the pocket naturally
within 28 days.

18. Subgingival Minocycline
 A bacteriostatic antibiotic
 Film, microspheres, and ointment.
Film:
 Ethyl cellulose film containing 30% of Minocycline were tested as
sustained release
 Complete eradication of pathogenic flora from the pocket after 14 days

19. Microsphere
 ARESTIN
 The 2% minocycline is encapsulated into bio-resorbable microspheres
(20-60μm in diameter) in a gel carrier and has resorption time of 21 days.

20. Ointment
■ 2% minocycline hydrochloride in a matrix of hydroxyethyl-cellulose,
amino alkyl-methacrylate, triacetine & glycerine.
■ The concentration of minocycline in the periodontal pocket is about
1300μg/ml, 1 hour after single topical application of 0.05 ml ointment
(1mg of minocycline) and is reduced to 90μg/ml after 7 hrs.

21. Chlorhexidine
 Is available in the form of mouthrinses, Gels, varnishes,
and chip to be used as a local drug delivery agent .
 Chlorhexidine has been shown to be an effective agent in plaque
inhibition (Loe et al 1976).
 Because it is well retained in the oral cavity, Reacting reversibly with
receptors in the mouth due to its affinity for hydroxyapetite and acidic
salivary protein.

22. Periochip
■ Small chip (4.5× 3.5mm) composed of biodegradable, hydrolyzed
gelatin matrix, 2.5mg chlorhexidine gluconate is incorporated.
■ Perio Chip releases chlorhexidine in a biphasic manner,

23.  Periocol-CG: Periocol CG is prepared by incorporating 2.5mg chlorhexidine
from a 20% chlorhexidine solution in collagen membrane. Size of the chip is
4x5 mm and thickness is 0.25 - 0.32 mm and 10 mg wt..

24. Subgingival Metronidazole
 Elyzol 25%
 Concentrations of above100 μ/ml - 8 hours
 Concentrations above 1 μ/ml - 36 hours.
 Applied in viscous consistency to the pocket, where it is liquidized by the
body heat and then hardens again, forming crystals in contact with water.

25. Herbs For Local Drug Delivery
 Neem has also showed better efficacy in the treatment of oral infections
and plaque growth inhibition in treating periodontal disorders.
 Neem has also shown good in vitro, broad range antibacterial activity.

26.  Roobal Bahal et al -2% turmeric gel , significant reduction in the mean
plaque index gingival index , sulcus bleeding index , probing pocket
depth and significant reduction in trypsin like enzymes activity of “Red-
Complex” microorganisms.

27. Aloe Vera
 Geeta Bhat et al in her study concluded that its use in local drug delivery
results in significant reduction in pocketdepth and resulted in reduction in
the gingival index.

28. Local Delivery Of Growth Factors
 Fibroblast growth factor would be a very efficacious introduction in
local drug delivery.
 To regenerate periodontal tissues, a sandwich membrane composed of a
collagen sponge scaffold and gelatin microspheres containing basic
fibroblast growth factor (bFGF) in a controlled-release system was
developed.(Cooke JW et al 2006)

30. Newer Trends In Local Drug Delivery
DRUGS FOR OSSEOUS DEFECTS
 Alendronate a novel bisphosphonate is a very potent inhibitor of bone
resorption.
 Local delivery of 1% ALN into periodontal pockets as an adjunct to SRP
stimulated a significant increase in PD reduction, CAL gain, and improved
bone fill (Anuj Sharma et al,2011)

31.  Simavastatin -Statins seem to modulate bone formation by increasing the
expression of bone morphogenetic protein-2, inflammation, and
angiogenesis.
 Pardeep et al showed a greater decrease in gingival index and probing
depth and a clinical attachment level gain with significant defect fill at
sites treated with scaling and root planing plus locally delivered SMV gel
in patients with chronic periodontitis.

32. Clarithromycin gel
 Adjunctive use of 0.5% clarithromycin as a controlled drug delivery
system enhanced the clinical outcome in smokers(Agarwal E etal)
 Okade et al - developed a new sub gingival release delivery system
containing Ofloxacin for sub gingival therapy

33. COLLOIDAL DRUG CARRIERS
 It include emulsions, liposomes and nanoparticles (nanospheres and
nanocapsules).
 The aim of using colloidal carriers is
To increase the specificity towards cells or tissues,
To improve the bioavailability of drugs by increasing their
diffusion through biological membranes and
To protect them against enzyme inactivation.

34. Clinical studies

35. Aloe vera: Nature's soothing healer to
periodontal disease
■ Geetha Bhat, Praveen in 2011
■ A total number of 15 subjects were evaluated for clinical parameters like plaque index,
gingival index, probing pocket depth at baseline, followed by scaling and root planing
(SRP).
■ Results: Results exhibited encouraging findings in clinical parameters of the role of
Aloe vera gel as a drug for local delivery.
■ Conclusion: she conclude that subgingival administration of Aloe vera gel results in
improvement of periodontal condition. Aloe vera gel can be used as a local drug delivery
system in periodontal pockets. Kudva, Vidya Dodwad

36. Evaluation of local drug-delivery system containing 2% whole
turmeric gel used as an adjunct to scaling and root planing in
chronic periodontitis: A clinical and microbiological study
■ Roobal Behal, Amita M. Mali, [...], and Anant R. Paradkar in 2011
■ The experimental local drug-delivery system containing 2% whole turmeric gel can be
effectively used as an adjunct to scaling and root planing and is more effective than
scaling and root planing alone in the treatment of periodontal pockets.

37. Efficacy of 10% whole Azadirachta indica (neem) chip as an
adjunct to scaling and root planning in chronic periodontitis:
A clinical and microbiological study.
■ Vennila K et al in 2016
■ After scaling and root planning (SRP), 10% nonabsorbable neem chip was placed in
the pocket in one side of the arch. Other side was done with SRP only. Clinical
parameters were recorded on the baseline, 7th day, and 21st day.
■ Clinical parameters showed statistically improved on the neem chip sites and presence
of P. gingivalis strains were significantly reduced on the neem chip sites.

38. ■ Nitesh Kumar Sharma et al in 2017
■ Clinical parameters were assesed at base line, 30 days and 90 days whereas the total
count was calculated at baseline, 30 days and 90 days.
■ Result: There was significant decrease in mean probing depth from base line to 90
days, and also there was significant gain in CAL in the test group as compared to
control group. There was a significant reduction in the total colony count from base
line to 21 days in both the group, but more reduction was observed in the test
group.

39. Effect of hyaluronan and metronidazole gels in
management of chronic periodontitis
■ Athraa Ali Mahmood, Ghasaq AAbdul-Wahab, Sarah I Al-Karawi
■ Group 1 (G1): treated with RSD and subgingival application of 1 mL from (0.2%) HA
gel to the base of the pocket
■ Group 2 (G2): treated with RSD and subgingival application of 1 mL from MTZ gel to
the base of the pocket
■ Group 3 (G3): treated with RSD alone.

40. Locally Delivered Doxycycline During Supportive
Periodontal Therapy: A 3‐Year Study
■ Jan L. Wennstro.M , 2016
■ Significant reductions in BOP, PD, RAL, and the mean counts of a number of target
species between baseline and 3 years were documented for both treatment groups,
whereas plaque scores remained unchanged.

41. CONCLUSION
■ There is ample evidence to show that locally delivered antimicrobials can
reduce clinical and microbial parameters to a level, if not better than, at least
comparable to that of scaling and root planing.
■ Local drug delivery is simple to use and may conceivably in the future be
delivered by the patients themselves, hence can be used as an adjunct to
mechanical plaque removal.

42. REFERENCES
 Clinical Periodontology
- Carranza 9th/10 th edition
 Clinical Periodontology & Implant Dentistry
- Jan Lindhe 5 edition
■ Local Drug Delivery in periodontal diseases. ……A Review, Amitha Ramesh , Agumbe
Priyanka Prakash & Biju Thoma
■ Local delivery of antimicrobial agents in theperiodontal pocket, THOMAES. RAMS&
JBRGEN SLOTS, Perio2000, Vol. 10, 1996, 139-159
■ K. Schwach-Abdellaouia, N. Vivien-Castionib, R. Gurny. Local delivery of antimicrobial
agents for the treatment of periodontal diseases. European Journal of Pharmaceutics and
Biopharmaceutics 50 (2000) 83-99.
■ Mahesh R. Dabhi et.al. Formulation development of smart gel periodontal drug delivery
system for local delivery of chemotherapeutic agents with application of experimental
design. Drug Delivery, 2010; 17(7): 520–531.