This document provides an overview of local drug delivery (LDD) in the treatment of periodontal diseases. It discusses the history, classification, indications, advantages, and devices used in LDD. Common agents delivered locally include tetracycline, doxycycline, minocycline, and chlorhexidine. Devices include fibers, films, gels, strips, and nanoparticle systems. Tetracycline fibers and doxycycline gels are among the most widely used commercially. Studies show that LDD of antibiotics provides higher drug concentrations in periodontal pockets and enhances the benefits of scaling and root planing for periodontal treatment.
The document discusses gingival curettage, which involves using instruments to remove diseased soft tissue from periodontal pockets. It defines curettage and provides the history of the procedure. The basic technique is described as using curettes to scrape the inner lining of the pocket to remove ulcerated epithelium and damaged connective tissue. Indications include edematous pockets aiming to reduce inflammation and shrink tissue. Healing after curettage is examined through a study showing revascularization of the wound site over time.
Guided tissue regeneration (GTR) uses barrier membranes to exclude epithelial and gingival connective tissue from accessing root surfaces in order to promote regeneration of periodontal tissues. The key concepts of GTR include Melcher's concept that the cell type which repopulates the root surface determines attachment outcomes. Non-resorbable and resorbable membranes have been developed for use as barriers in GTR procedures. Factors like patient characteristics, defect morphology, surgical technique, and membrane properties influence clinical outcomes of GTR for treating conditions like intrabony defects.
This document discusses chemically modified tetracyclines (CMTs), a group of drugs developed from tetracyclines that lack antimicrobial properties but retain anti-collagenase activity. CMTs have several potential benefits, including inhibiting matrix metalloproteinases (MMPs), reducing proinflammatory mediators, inhibiting bone resorption, and scavenging reactive oxygen species. While CMTs show promise for treating conditions like periodontitis, they have not been fully approved for human use due concerns around excessive MMP suppression and other side effects.
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.
Scaling and root planing (SRP) is a non-surgical treatment for periodontitis that aims to remove dental plaque and calculus from tooth surfaces. It involves scaling to remove deposits and root planing to smooth root surfaces. The goals are to eliminate periodontitis by removing irritants and restoring a healthy environment for tissue healing. The long-term effectiveness depends on factors like patient compliance, disease severity, and anatomical challenges. Overhanging restorations can interfere with cleaning and disturb the ecological balance, allowing disease-causing bacteria to proliferate.
The document summarizes the key phases and techniques involved in nonsurgical periodontal therapy (NSPT). It discusses the goals of NSPT to eliminate pathogens and halt disease progression. Techniques include scaling and root planing to remove calculus, contaminated cementum, and bacterial toxins. Studies found that aggressive root planing is not needed and that clinical improvements result from scaling alone or with root planing. The effects of NSPT on subgingival microflora and selection of instrumentation techniques are also summarized.
This document discusses crown lengthening procedures and biological width. It defines biological width as the natural distance between the base of the gingival sulcus and alveolar bone, which is typically 2mm. Crown lengthening surgically exposes more tooth structure above the bone to avoid violating the biological width and prevent inflammation. The document outlines different types of crown lengthening procedures based on the available soft and hard tissue dimensions, as well as factors to consider like gingival biotype and restoration design. Maintaining at least 3mm of tooth structure above bone is recommended to allow for proper restorative margins and healing.
Non Surgical Periodontal Therapy by Dr Santosh Martandesantoshmds
Review and Essay Material on Non Surgical Periodontal Therapy. Illustrative Contents for proper presentation on all aspects of NSPT. The Presentation helps in drafting A to Z of NSPT. Readers are encouraged to add newer studies and ideas under each aspect of NSPT.
The document discusses gingival curettage, which involves using instruments to remove diseased soft tissue from periodontal pockets. It defines curettage and provides the history of the procedure. The basic technique is described as using curettes to scrape the inner lining of the pocket to remove ulcerated epithelium and damaged connective tissue. Indications include edematous pockets aiming to reduce inflammation and shrink tissue. Healing after curettage is examined through a study showing revascularization of the wound site over time.
Guided tissue regeneration (GTR) uses barrier membranes to exclude epithelial and gingival connective tissue from accessing root surfaces in order to promote regeneration of periodontal tissues. The key concepts of GTR include Melcher's concept that the cell type which repopulates the root surface determines attachment outcomes. Non-resorbable and resorbable membranes have been developed for use as barriers in GTR procedures. Factors like patient characteristics, defect morphology, surgical technique, and membrane properties influence clinical outcomes of GTR for treating conditions like intrabony defects.
This document discusses chemically modified tetracyclines (CMTs), a group of drugs developed from tetracyclines that lack antimicrobial properties but retain anti-collagenase activity. CMTs have several potential benefits, including inhibiting matrix metalloproteinases (MMPs), reducing proinflammatory mediators, inhibiting bone resorption, and scavenging reactive oxygen species. While CMTs show promise for treating conditions like periodontitis, they have not been fully approved for human use due concerns around excessive MMP suppression and other side effects.
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.
Scaling and root planing (SRP) is a non-surgical treatment for periodontitis that aims to remove dental plaque and calculus from tooth surfaces. It involves scaling to remove deposits and root planing to smooth root surfaces. The goals are to eliminate periodontitis by removing irritants and restoring a healthy environment for tissue healing. The long-term effectiveness depends on factors like patient compliance, disease severity, and anatomical challenges. Overhanging restorations can interfere with cleaning and disturb the ecological balance, allowing disease-causing bacteria to proliferate.
The document summarizes the key phases and techniques involved in nonsurgical periodontal therapy (NSPT). It discusses the goals of NSPT to eliminate pathogens and halt disease progression. Techniques include scaling and root planing to remove calculus, contaminated cementum, and bacterial toxins. Studies found that aggressive root planing is not needed and that clinical improvements result from scaling alone or with root planing. The effects of NSPT on subgingival microflora and selection of instrumentation techniques are also summarized.
This document discusses crown lengthening procedures and biological width. It defines biological width as the natural distance between the base of the gingival sulcus and alveolar bone, which is typically 2mm. Crown lengthening surgically exposes more tooth structure above the bone to avoid violating the biological width and prevent inflammation. The document outlines different types of crown lengthening procedures based on the available soft and hard tissue dimensions, as well as factors to consider like gingival biotype and restoration design. Maintaining at least 3mm of tooth structure above bone is recommended to allow for proper restorative margins and healing.
Non Surgical Periodontal Therapy by Dr Santosh Martandesantoshmds
Review and Essay Material on Non Surgical Periodontal Therapy. Illustrative Contents for proper presentation on all aspects of NSPT. The Presentation helps in drafting A to Z of NSPT. Readers are encouraged to add newer studies and ideas under each aspect of NSPT.
This document discusses and classifies various acute gingival infections including traumatic lesions, viral infections like herpetic gingivostomatitis, bacterial infections like necrotizing ulcerative gingivitis, fungal diseases, gingival abscesses, aphthous ulcers, erythema multiforme, and drug allergies. It provides detailed information on necrotizing ulcerative gingivitis including causes, signs and symptoms, stages, predisposing factors, relationship to bacteria, and treatment approaches. It also summarizes acute herpetic gingivostomatitis, recurrent aphthous stomatitis, and pericoronitis covering causes, clinical features, types
Periodontitis is a complex infection initiated by bacteria –tissue destruction.
Host: the organism from which a parasite obtains its nourishment/ an individual who receives a graft
Modulation: the alteration of function or status of something in response to a stimulus or an altered physical or chemical environment
The document discusses the effects of hormones from various endocrine glands on the periodontium. It describes how hormones from the hypothalamus and pituitary gland regulate other endocrine glands. It then examines the specific effects of hormones from the adrenal, thyroid, parathyroid, gonads and pancreas on periodontal tissues and the mechanisms by which they may influence periodontal health and disease. It also discusses how gender, age and hormone supplements can impact the effects of sex hormones on the periodontium.
Pathologic tooth migration (PTM) refers to tooth displacement resulting from a disturbance in factors that maintain normal tooth position. PTM is common in periodontal patients, with prevalence studies finding rates of 30-55%. The primary factor in PTM is periodontal bone loss resulting from periodontal disease. Other factors include occlusal changes from tooth loss, soft tissue pressures, oral habits, and periapical or gingival inflammation. Treatment involves periodontal therapy, sometimes with adjunctive orthodontics or prosthodontics, while prevention focuses on periodontal disease control and management of predisposing occlusal and habit factors.
This document discusses the influence of systemic conditions on the periodontium. It begins by introducing periodontitis as a chronic bacterial infection and how host responses can vary between individuals. Systemic disorders can impair the host's immune defenses, creating opportunities for more severe periodontal disease. Several specific systemic factors are then examined in more detail, including hormonal changes, diabetes mellitus, and female sex hormones. The effects of these conditions on the periodontium are explored through their impact on factors like subgingival microbiota, polymorphonuclear leukocyte function, collagen metabolism, and wound healing. Treatment considerations for periodontal disease in systemic disease patients are also briefly addressed.
This document discusses various techniques for non-surgical periodontal therapy, focusing on root planing. It defines root planing as the removal of plaque, calculus, and contaminated cementum and dentin from root surfaces. It discusses the rationale for root planing, including the removal of diseased cementum that may contain toxins. It evaluates different root planing instruments like curettes and ultrasonic scalers. While some studies found root smoothness and cementum removal were unnecessary, most support root planing to remove toxins and prepare the surface for new attachment. The document analyzes debates around techniques and their role in resolving inflammation and facilitating healing.
This document discusses local drug delivery (LDD) for the treatment of periodontal disease. It begins with an introduction to LDD and its advantages over systemic antibiotics. It describes the goal of LDD as achieving therapeutic drug levels in the periodontal pocket for effective treatment. The document discusses various LDD methods including non-sustained and sustained release delivery systems. It covers indications, contraindications, advantages and disadvantages of LDD. Various classifications of LDD systems and commonly used drugs are also summarized.
The document discusses the defense mechanisms of the gingiva that help it withstand various adverse environmental conditions. There are nonspecific and specific defense mechanisms. Nonspecific mechanisms include the anatomical structure of the gingiva, the mucous barrier formed by saliva and gingival crevicular fluid, and tissue resistance. Specific mechanisms include the host-microbial symbiosis provided by beneficial commensal bacteria and the local inflammatory response. Saliva plays an important role through its antibacterial factors such as antibodies, enzymes, and buffers that help maintain pH and protect against pathogens. The gingival crevicular fluid also acts as a permeable barrier, with its production increased during inflammation. These defense mechanisms work together to keep the
This document discusses refractory periodontitis. It begins by defining refractory periodontitis as a destructive periodontal disease where patients continue to experience attachment loss at sites despite conventional therapy. Several studies are summarized that investigated clinical features and microbial profiles of refractory periodontitis patients. In general, the studies found heterogeneity in clinical presentation and microbial profiles of refractory patients. Certain bacteria like Enterococcus faecalis and Streptococcus species were found at higher levels in refractory patients. The document concludes by discussing treatment considerations for refractory periodontitis, such as using antibiotics and intensified maintenance programs.
The document discusses gingival curettage, which involves scraping the lining of periodontal pockets to remove diseased soft tissue. It aims to reduce pocket depth and promote new connective tissue attachment. Gingival curettage specifically refers to removing tissue lateral to the pocket wall, while subgingival curettage is performed below the epithelial attachment to sever the connection to bone. The document outlines the procedure, healing process, indications, contraindications and potential complications of gingival curettage.
Refractory periodontitis refers to chronic periodontal disease that responds poorly to conventional treatment such as scaling and root planing. About 10-15% of patients have refractory periodontitis. Several studies examined clinical, microbiological, and immunological parameters to better diagnose and treat refractory periodontitis. One study found that levels of certain bacterial species, percentage of sites with deep pockets, and number of bacterial species with high antibody levels could predict refractory cases. Another study found elevated antibody levels to specific bacteria correlated with refractory cases. Molecular studies identified higher expression of certain genes involved in inflammation and bone resorption in refractory patients. Microarray analysis found refractory patients had persistent pathogenic bacteria after treatment. Combin
1. Controversies exist in many areas of periodontology including disease diagnosis and classification, microbial aspects, pathogenesis, and various treatment modalities such as periodontal, implant, and mucogingival therapies.
2. Dogmas that were previously held as undisputed truths are now being challenged by new evidence, with debates around issues like the definition of biologic width, need for splinting, and thresholds for peri-implant disease diagnosis.
3. Mapping techniques can help explore controversies through non-controversial elements, literature analysis, review of opinions, networks of relationships, and chronologies to better understand disagreements.
Surgical v/s Non surgical periodontal therapy Achi Joshi
Both surgical and nonsurgical therapy produced improvement in the periodontal health.
Treatment approach was based on the comfort level of the practitioner.
In the late 60’s and continuing into the 70’s and 80’s, many series of longitudinal studies were conducted, aimed to document the immediate and most importantly long term clinical results following several types of periodontal therapy.
Every periodontal surgical procedure has its own indications. With proper knowledge of the etiology of the disease, correct diagnosis and treatment planning, the clinician is able to draw predictable success with periodontal flap surgery.
The defense mechanism of gingiva includes GCF, Saliva, epithelial barrier and connective tissue cells. All these protect the periodontium from bacterial invasion.
This document discusses the historical background and various methods of root biomodification, which involves chemically or mechanically modifying the root surface to promote periodontal regeneration. It describes how citric acid, tetracycline, fibronectin, and EDTA work to demineralize and detoxify the root surface in order to remove the smear layer and expose collagen fibers, making the surface more biocompatible and conducive to new attachment of periodontal tissues. Register and Burdick's 1975 technique using citric acid application for 2-3 minutes is outlined, along with modifications by Miller. The mechanisms and benefits of different agents are explained.
Aggressive periodontitis is a rare, severe form of periodontitis characterized by rapid attachment and bone loss. It is defined by early onset, familial aggregation, and microbial features including elevated levels of Aggregatibacter actinomycetemcomitans and Porphyromonas gingivalis. Treatment involves non-surgical therapy such as scaling and root planing along with adjunctive antibiotic therapy targeting the causative bacteria. If non-surgical therapy is insufficient, surgical treatment may also be used in combination with antibiotics to gain access to deep pockets and remove infected tissue. The goals of treatment are to eliminate the pathogenic bacteria, arrest disease progression, and regenerate lost periodontal structures.
The document discusses the role of occlusion in periodontal disease. It defines occlusion and classifies occlusion types. It explores the biological basis of occlusal function and the relationship between occlusal disharmony and periodontal disease. Occlusal trauma from hyperfunction, hypofunction, and parafunctions like bruxism can impact periodontal tissues. The document outlines methods for clinical diagnosis and developing treatment plans involving occlusal therapy, adjustment, and splinting to address occlusal factors and support periodontal treatment.
Diagnostic test and investigation in periodontology Dr Abhilasha
This document provides an overview of investigations used in dental diagnosis. It begins by defining diagnosis and the role of laboratory investigations. It then classifies investigations based on where they are performed (chairside or laboratory), their specificity/sensitivity, the type of hospital laboratory service used, and frequency of dental use. The remainder of the document discusses various chairside and laboratory investigations in hematology, biochemistry, microbiology, and imaging that are used in dentistry.
The document discusses implants and inserts as drug delivery systems. It defines implants as single unit drug delivery systems designed to deliver a drug over a prolonged period of time. Implants can be biodegradable or non-biodegradable and come in various shapes, sizes, and drug release mechanisms. The document then discusses the advantages and disadvantages of implants, ideal characteristics, mechanisms of drug release including diffusion controlled and activated controlled systems, approaches to development, types of devices based on route of administration, and evaluation of implants.
LOCAL DRUG DELIVERY agents in periodontisticshashimedavath
This document discusses local drug delivery systems for treating periodontitis. It begins with an introduction to periodontitis and the goals of local drug delivery. Some key points made include: local drug delivery aims to target anti-infective agents to infection sites to kill pathogens without harming tissues; it has advantages over mouth rinses and systemic delivery by achieving higher drug concentrations directly in pockets. The document then covers various local drug delivery classifications, products, vehicles, and drugs used like tetracycline fibers, chlorhexidine chips, and doxycycline gels. It compares the pharmacokinetics of different delivery methods and concludes local delivery is effective for maintaining therapeutic drug levels in pockets long-term.
This document discusses and classifies various acute gingival infections including traumatic lesions, viral infections like herpetic gingivostomatitis, bacterial infections like necrotizing ulcerative gingivitis, fungal diseases, gingival abscesses, aphthous ulcers, erythema multiforme, and drug allergies. It provides detailed information on necrotizing ulcerative gingivitis including causes, signs and symptoms, stages, predisposing factors, relationship to bacteria, and treatment approaches. It also summarizes acute herpetic gingivostomatitis, recurrent aphthous stomatitis, and pericoronitis covering causes, clinical features, types
Periodontitis is a complex infection initiated by bacteria –tissue destruction.
Host: the organism from which a parasite obtains its nourishment/ an individual who receives a graft
Modulation: the alteration of function or status of something in response to a stimulus or an altered physical or chemical environment
The document discusses the effects of hormones from various endocrine glands on the periodontium. It describes how hormones from the hypothalamus and pituitary gland regulate other endocrine glands. It then examines the specific effects of hormones from the adrenal, thyroid, parathyroid, gonads and pancreas on periodontal tissues and the mechanisms by which they may influence periodontal health and disease. It also discusses how gender, age and hormone supplements can impact the effects of sex hormones on the periodontium.
Pathologic tooth migration (PTM) refers to tooth displacement resulting from a disturbance in factors that maintain normal tooth position. PTM is common in periodontal patients, with prevalence studies finding rates of 30-55%. The primary factor in PTM is periodontal bone loss resulting from periodontal disease. Other factors include occlusal changes from tooth loss, soft tissue pressures, oral habits, and periapical or gingival inflammation. Treatment involves periodontal therapy, sometimes with adjunctive orthodontics or prosthodontics, while prevention focuses on periodontal disease control and management of predisposing occlusal and habit factors.
This document discusses the influence of systemic conditions on the periodontium. It begins by introducing periodontitis as a chronic bacterial infection and how host responses can vary between individuals. Systemic disorders can impair the host's immune defenses, creating opportunities for more severe periodontal disease. Several specific systemic factors are then examined in more detail, including hormonal changes, diabetes mellitus, and female sex hormones. The effects of these conditions on the periodontium are explored through their impact on factors like subgingival microbiota, polymorphonuclear leukocyte function, collagen metabolism, and wound healing. Treatment considerations for periodontal disease in systemic disease patients are also briefly addressed.
This document discusses various techniques for non-surgical periodontal therapy, focusing on root planing. It defines root planing as the removal of plaque, calculus, and contaminated cementum and dentin from root surfaces. It discusses the rationale for root planing, including the removal of diseased cementum that may contain toxins. It evaluates different root planing instruments like curettes and ultrasonic scalers. While some studies found root smoothness and cementum removal were unnecessary, most support root planing to remove toxins and prepare the surface for new attachment. The document analyzes debates around techniques and their role in resolving inflammation and facilitating healing.
This document discusses local drug delivery (LDD) for the treatment of periodontal disease. It begins with an introduction to LDD and its advantages over systemic antibiotics. It describes the goal of LDD as achieving therapeutic drug levels in the periodontal pocket for effective treatment. The document discusses various LDD methods including non-sustained and sustained release delivery systems. It covers indications, contraindications, advantages and disadvantages of LDD. Various classifications of LDD systems and commonly used drugs are also summarized.
The document discusses the defense mechanisms of the gingiva that help it withstand various adverse environmental conditions. There are nonspecific and specific defense mechanisms. Nonspecific mechanisms include the anatomical structure of the gingiva, the mucous barrier formed by saliva and gingival crevicular fluid, and tissue resistance. Specific mechanisms include the host-microbial symbiosis provided by beneficial commensal bacteria and the local inflammatory response. Saliva plays an important role through its antibacterial factors such as antibodies, enzymes, and buffers that help maintain pH and protect against pathogens. The gingival crevicular fluid also acts as a permeable barrier, with its production increased during inflammation. These defense mechanisms work together to keep the
This document discusses refractory periodontitis. It begins by defining refractory periodontitis as a destructive periodontal disease where patients continue to experience attachment loss at sites despite conventional therapy. Several studies are summarized that investigated clinical features and microbial profiles of refractory periodontitis patients. In general, the studies found heterogeneity in clinical presentation and microbial profiles of refractory patients. Certain bacteria like Enterococcus faecalis and Streptococcus species were found at higher levels in refractory patients. The document concludes by discussing treatment considerations for refractory periodontitis, such as using antibiotics and intensified maintenance programs.
The document discusses gingival curettage, which involves scraping the lining of periodontal pockets to remove diseased soft tissue. It aims to reduce pocket depth and promote new connective tissue attachment. Gingival curettage specifically refers to removing tissue lateral to the pocket wall, while subgingival curettage is performed below the epithelial attachment to sever the connection to bone. The document outlines the procedure, healing process, indications, contraindications and potential complications of gingival curettage.
Refractory periodontitis refers to chronic periodontal disease that responds poorly to conventional treatment such as scaling and root planing. About 10-15% of patients have refractory periodontitis. Several studies examined clinical, microbiological, and immunological parameters to better diagnose and treat refractory periodontitis. One study found that levels of certain bacterial species, percentage of sites with deep pockets, and number of bacterial species with high antibody levels could predict refractory cases. Another study found elevated antibody levels to specific bacteria correlated with refractory cases. Molecular studies identified higher expression of certain genes involved in inflammation and bone resorption in refractory patients. Microarray analysis found refractory patients had persistent pathogenic bacteria after treatment. Combin
1. Controversies exist in many areas of periodontology including disease diagnosis and classification, microbial aspects, pathogenesis, and various treatment modalities such as periodontal, implant, and mucogingival therapies.
2. Dogmas that were previously held as undisputed truths are now being challenged by new evidence, with debates around issues like the definition of biologic width, need for splinting, and thresholds for peri-implant disease diagnosis.
3. Mapping techniques can help explore controversies through non-controversial elements, literature analysis, review of opinions, networks of relationships, and chronologies to better understand disagreements.
Surgical v/s Non surgical periodontal therapy Achi Joshi
Both surgical and nonsurgical therapy produced improvement in the periodontal health.
Treatment approach was based on the comfort level of the practitioner.
In the late 60’s and continuing into the 70’s and 80’s, many series of longitudinal studies were conducted, aimed to document the immediate and most importantly long term clinical results following several types of periodontal therapy.
Every periodontal surgical procedure has its own indications. With proper knowledge of the etiology of the disease, correct diagnosis and treatment planning, the clinician is able to draw predictable success with periodontal flap surgery.
The defense mechanism of gingiva includes GCF, Saliva, epithelial barrier and connective tissue cells. All these protect the periodontium from bacterial invasion.
This document discusses the historical background and various methods of root biomodification, which involves chemically or mechanically modifying the root surface to promote periodontal regeneration. It describes how citric acid, tetracycline, fibronectin, and EDTA work to demineralize and detoxify the root surface in order to remove the smear layer and expose collagen fibers, making the surface more biocompatible and conducive to new attachment of periodontal tissues. Register and Burdick's 1975 technique using citric acid application for 2-3 minutes is outlined, along with modifications by Miller. The mechanisms and benefits of different agents are explained.
Aggressive periodontitis is a rare, severe form of periodontitis characterized by rapid attachment and bone loss. It is defined by early onset, familial aggregation, and microbial features including elevated levels of Aggregatibacter actinomycetemcomitans and Porphyromonas gingivalis. Treatment involves non-surgical therapy such as scaling and root planing along with adjunctive antibiotic therapy targeting the causative bacteria. If non-surgical therapy is insufficient, surgical treatment may also be used in combination with antibiotics to gain access to deep pockets and remove infected tissue. The goals of treatment are to eliminate the pathogenic bacteria, arrest disease progression, and regenerate lost periodontal structures.
The document discusses the role of occlusion in periodontal disease. It defines occlusion and classifies occlusion types. It explores the biological basis of occlusal function and the relationship between occlusal disharmony and periodontal disease. Occlusal trauma from hyperfunction, hypofunction, and parafunctions like bruxism can impact periodontal tissues. The document outlines methods for clinical diagnosis and developing treatment plans involving occlusal therapy, adjustment, and splinting to address occlusal factors and support periodontal treatment.
Diagnostic test and investigation in periodontology Dr Abhilasha
This document provides an overview of investigations used in dental diagnosis. It begins by defining diagnosis and the role of laboratory investigations. It then classifies investigations based on where they are performed (chairside or laboratory), their specificity/sensitivity, the type of hospital laboratory service used, and frequency of dental use. The remainder of the document discusses various chairside and laboratory investigations in hematology, biochemistry, microbiology, and imaging that are used in dentistry.
The document discusses implants and inserts as drug delivery systems. It defines implants as single unit drug delivery systems designed to deliver a drug over a prolonged period of time. Implants can be biodegradable or non-biodegradable and come in various shapes, sizes, and drug release mechanisms. The document then discusses the advantages and disadvantages of implants, ideal characteristics, mechanisms of drug release including diffusion controlled and activated controlled systems, approaches to development, types of devices based on route of administration, and evaluation of implants.
LOCAL DRUG DELIVERY agents in periodontisticshashimedavath
This document discusses local drug delivery systems for treating periodontitis. It begins with an introduction to periodontitis and the goals of local drug delivery. Some key points made include: local drug delivery aims to target anti-infective agents to infection sites to kill pathogens without harming tissues; it has advantages over mouth rinses and systemic delivery by achieving higher drug concentrations directly in pockets. The document then covers various local drug delivery classifications, products, vehicles, and drugs used like tetracycline fibers, chlorhexidine chips, and doxycycline gels. It compares the pharmacokinetics of different delivery methods and concludes local delivery is effective for maintaining therapeutic drug levels in pockets long-term.
This document discusses various drug delivery systems. It begins by describing conventional delivery systems like pills and injections. It then defines controlled drug delivery as combining a drug with a carrier to release it in a predetermined manner. New techniques allow controlling the rate, targeting the delivery site, and responding to environmental changes. The need is for more effective therapies while avoiding under- and overdosing. Various delivery mechanisms, materials, carriers, and examples are provided. The document also discusses transdermal, pulmonary, and ocular delivery systems. It concludes by mentioning floating oral delivery systems that increase gastric emptying time and target the colon.
Mucoadhesive drug delivery system interact with the mucus layer covering the mucosal epithelial surface, & mucin molecules & increase the residence time of the dosage form at the site of the absorption.
Mucoadhesive drug delivery system is a part of controlled delivery system.
Since the early 1980,the concept of Mucoadhesion has gained considerable interest in pharmaceutical technology.
combine mucoadhesive with enzyme inhibitory & penetration enhancer properties & improve the patient complaince.
MDDS have been devloped for buccal ,nasal,rectal &vaginal routes for both systemic & local effects.
Hydrophilic high mol. wt. such as peptides that cannot be administered & poor absorption ,then MDDS is best choice.
Mucoadhesiveinner layers called mucosa inner epithelial cell lining is covered with viscoelasticfluid
Composed of water and mucin.
Thickness varies from 40 μm to 300 μm
General composition of mucus
Water…………………………………..95%
Glycoproteinsand lipids……………..0.5-5%
Mineral salts……………………………1%
Free proteins…………………………..0.5-1%
The mechanism responsible in the formation of mucoadhesive bond
Step 1 : Wetting and swelling of the polymer(contact stage)
Step 2 : Interpenetration between the polymer chains and the mucosal membrane
Step 3 : Formation of bonds between the entangled chains (both known as consolidation stage)
Electronic theory
Wetting theory
Adsorption theory
Diffusion theory
Fracture theory
Advantages over other controlled oral controlled release systems by virtue of prolongation of residence of drug in GIT.
Targeting & localization of the dosage form at a specific site
-Painless administration.
-Low enzymatic activity & avoid of first pass metabolism
If MDDS are adhere too tightlgy because it is undesirable to exert too much force to remove the formulation after use,otherwise the mucosa could be injured.
-Some patient suffers unpleasent feeling.
-Unfortunately ,the lack of standardized techniques often leads to unclear results.
-costly drug delivery system
The document discusses local drug delivery for periodontal disease treatment. It describes the rationale for local delivery over systemic administration, including reducing side effects and bacterial resistance. The advantages of local delivery include improved patient acceptance and targeting of treatment. Various local delivery devices are outlined, including fibers, strips, films, injectable systems, and gels. The devices aim to provide sustained drug release at therapeutic levels for several days. Limitations include potential local irritation and short drug release times for some devices. Clinical studies demonstrate the ability of some devices to maintain effective drug concentrations and reduce the need for invasive periodontal procedures.
This document discusses local drug delivery for the treatment of periodontitis. It begins by introducing periodontitis and current nonsurgical treatments. It then discusses the rationale for localized drug delivery directly into periodontal pockets, including achieving higher drug concentrations at the site of infection while reducing systemic exposure. Several routes of local delivery are described, including mouth rinses, subgingival irrigation, and local drug delivery systems like fibers, films, and injectable gels. The document covers the development of local delivery devices, indications and contraindications for their use, advantages and disadvantages, and various drug delivery systems that have been investigated.
Basic to recent advances in local drug delivery also covering the effects of GCF flow on local drugs as well as use of local drugs used in periimplantitis.
Tetracyclines are broad-spectrum antibiotics introduced in the late 1940s that are primarily bacteriostatic. They interfere with bacterial protein synthesis and inhibit tissue collagenase activity. Tetracyclines are commonly used in managing periodontal diseases. They accumulate in teeth and bones and are excreted primarily through urine. Adverse effects include gastrointestinal issues and hepatotoxicity. Locally delivered tetracycline fibers and gels provide high drug concentrations in tissues while minimizing systemic exposure and side effects.
This document provides an overview of local drug delivery systems for periodontitis. It begins with introductions and definitions, then discusses the historical perspective. The objectives of local drug delivery are to deliver antimicrobials at effective concentrations to the periodontal pockets without systemic side effects. Various drug delivery systems are classified and described, including fibers, films, gels, strips, vesicles, microparticles, and nanoparticles. The document outlines the requirements, advantages, and impact of local drug delivery systems for treating periodontitis.
Implantable drug delivery systems provide sustained release of drugs over long periods of time through placement of drug-loaded implants under the skin. There are several types of implant systems including polymeric matrix systems where the drug is dispersed in a polymer, reservoir systems where the drug core is surrounded by a permeable membrane, and biodegradable systems where the implant breaks down over time. Implantable systems can last from weeks to years, improving patient compliance over oral medications by eliminating the need for repeated dosing. Several implantable drug delivery systems have been approved by the FDA to treat conditions like cancer, eye diseases, and bone infections.
This document discusses buccal drug delivery via the inner cheek mucosa. It notes the buccal mucosa provides advantages over other routes like avoiding first-pass metabolism, rapid absorption for quick onset of action, and ease of administration/termination of treatment. It outlines considerations for drug delivery like resisting enzymes and not damaging tissues. The document reviews factors impacting buccal delivery and design of buccal dosage forms like patches, tablets, films and gels. It lists examples of drugs delivered buccally and the experimental methods used to evaluate buccal permeation.
This document discusses trans mucosal drug delivery systems. It begins by comparing traditional drug delivery routes like oral and parenteral and their limitations. It then introduces trans mucosal delivery as an alternative that avoids first pass metabolism and provides controlled release. The document discusses the anatomy and characteristics of different mucosal sites. It also examines factors that influence trans mucosal delivery such as drug properties, biological factors, and formulation techniques. Finally, it reviews various trans mucosal delivery devices, methods for optimizing formulations, and quality control testing.
This document discusses methods of formulating and evaluating buccal drug delivery systems. It describes the basic structure and designs of buccal dosage forms as being matrix or reservoir types. The key components are outlined as the drug substance, bioadhesive polymers, backing membrane, and permeation enhancers. Various formulation methods are provided for solid, semi-solid and liquid buccal dosage forms including tablets, patches, films, gels and sprays. Evaluation methods are also summarized such as weight variation, thickness, friability, hardness, and in-vitro swelling studies.
This document discusses dissolution controlled and diffusion controlled drug delivery systems. It describes some key challenges with traditional drug delivery like short half-life, metabolism, and solubility issues that newer systems aim to address. Dissolution controlled systems control drug release through encapsulation or matrix devices as the polymer dissolves. Diffusion controlled systems use reservoir or matrix devices where the drug diffuses through a membrane at a controlled rate determined by properties like thickness. Both approaches can provide more consistent drug levels compared to traditional methods.
Antibiotic susceptibility testing بكتريا عملي في رحاب الله
The document discusses antimicrobial susceptibility testing. It begins by defining antibiotics and classifying different types of antibiotics based on their mechanism of action and targets, such as cell wall synthesis inhibitors and protein synthesis inhibitors. It then describes two common methods for antimicrobial susceptibility testing - the disk diffusion method and Etest. The disk diffusion method involves measuring the zone of inhibition around disks containing different antibiotics. The Etest provides minimum inhibitory concentration (MIC) values by using plastic strips with gradients of antibiotic concentrations. Interpretive criteria are used to determine if a bacteria is susceptible, intermediate, or resistant to a given antibiotic.
This document discusses various drug delivery technologies used by companies like Cipla to develop targeted therapies. It describes nanotechnology used to deliver drugs to specific cell types via engineered nanoparticles. Microsphere and microparticulate technologies are used for targeted and sustained delivery via injection or oral formulations. Liposomes, hot melt extrusion, and osmotic controlled release systems are also outlined as technologies to modify drug properties and target delivery. The aim is to improve efficacy, safety, and patient compliance through specialized delivery approaches.
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Diagnosis and Staging
The diagnosis of HR+ breast cancer begins with clinical evaluation, imaging, and biopsy. Imaging modalities such as mammography, ultrasound, and MRI help in assessing the extent of the disease. Histopathological examination and immunohistochemical staining of the biopsy sample confirm the diagnosis and hormone receptor status by identifying the presence of estrogen receptors (ER) and progesterone receptors (PR) on the tumor cells.
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Endocrine Therapy
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Selective Estrogen Receptor Modulators (SERMs): Tamoxifen is a SERM that binds to estrogen receptors, blocking estrogen from stimulating breast cancer cells. It is effective but may have side effects such as increased risk of endometrial cancer and thromboembolic events.
Aromatase Inhibitors (AIs): These drugs, including anastrozole, letrozole, and exemestane, lower estrogen levels by inhibiting the aromatase enzyme, which converts androgens to estrogen in peripheral tissues. AIs are generally preferred in postmenopausal women due to their efficacy and safety profile compared to tamoxifen.
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Endocrine Therapy with CDK4/6 Inhibitors: Palbociclib, ribociclib, and abemaciclib are CDK4/6 inhibitors that, when combined with endocrine therapy, significantly improve progression-free survival in advanced HR+ breast cancer.
Endocrine Therapy with mTOR Inhibitors: Everolimus, an mTOR inhibitor, can be added to endocrine therapy for patients who have developed resistance to aromatase inhibitors.
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4. To overcome this, Antimicrobials both systemic and locally acting were used as adjuncts to
mechanical therapy
• unfavorable anatomy of the tooth
•presence of tissue invasive organisms
• bacterial invasion into dentinal tubules
Quirynen et al (2002)
Limitations of mechanical debridement
5. drug toxicity
drug interaction
acquired bacterial resistance
Patient compliance
• Systemic antimicrobial agents may reduce or eliminate bacteria that cannot be removed by
scaling and root planning.
.. Adverse effects limit the use of systemic antimicrobials ..
6. Local delivery of antibacterial agents into periodontal pocket
limiting the drug to its target
site
Achieve high concentration at
target site
Dr. Max Goodson (1979) …. developed local delivery of therapeutic agents into a viable concept.
7. Local route of drug delivery can attain 100-fold higher
concentrations of an antimicrobial agent in subgingival sites
compared with a systemic drug regimen thereby reducing
the total patient dose by over 400 fold avoiding development
of drug-resistant at non oral body sites.
(Goodson J., 1994).
8. HISTORY
Initial efforts… flushing with antimicrobial agents….W.D. Miller .. 1880’s .. the use of
an antimicrobial mouthrinse (Listerine) to aid in fighting what was then known as
‘Pyorrhea alveolaris’.
The concept.. origin in the 1970’s based on the theory… if one could substantially
improve the cellular specificity of a drug there would be an accompanying
significant improvement in the therapeutic index;
Dr. Max GoodSon (1979… championed and developed controlled release local delivery
of therapeutic agents…
9.
10. CLASSIFICATION OF LOCAL ANTIMICROBIAL THERAPY IN PERIODONTICS
• based on their mechanism of action (Langer & Peppas (1988) --
Diffusion controlled systems
Chemically controlled systems
Solvent activated System
Release induced by external forces
13. Solvent activated
System
- Osmotic system
- Swelling controlled
system
Release induced by
external forces
Magnetically controlled
systems
14. Reservoir without rate
controlling system:
• hollow fibers filled with a
therapeutic agent in which the
agent is released simply by
diffusion through the reservoir
wall.
Reservoir devices with rate
controlling system:
• solvent action on coated drug
particles, microporous polymer
membrane or erodable polymeric
matrices.
-- based on the rate controlling system-- Kornman
15. PERSONALLY APPLIED
(In patient home self-care)
PROFESSIONALLY APPLIED
(In dental office)
NON-SUSTAINED SUBGINGIVAL DRUG
DELIVERY
SUSTAINED SUBGINGIVAL DRUG
DELIVERY
depending on the type of therapy.. Rams & slots(1996)
16. A) SUSTAINED
RELEASE DEVICES
Drug delivery for less than 24 hrs
require multiple applications
) CONTROLLED
DELIVERY DEVICES
Duration of drug release exceeds 24hrs
administered once
Based on duration of action (Greenstein & Tonetti 2000)
17. INDICATIONS
Isolated
periodontal
pockets
(>5mm), with
successful
phase 1 therapy
Periodontal
patients who
are medically
compromised
where surgical
therapy is
contraindicated.
In combination
with
mechanical
debridement
who are
suffering from
recurrent
periodontitis.
During
periodontal
regenerative
procedures.
19. ADVANTAGES:
• limit drug at the target site.
• No risk of emergence of resistant
microorganism.
• Minimizing the exposure of total body to
the drug.
• Sustained release of antimicrobial in the
periodontal pockets.
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.
•Do not markedly affect pathogens residing on
extra-pocket oral surfaces.
•Non-sustained drug delivery provides only a
brief exposure of the target microorganism to the
applied antimicrobial agent.
20. IDEAL REQUIREMENTS FOR LOCALANTIMICROBIAL AGENTS:
• Must deliver the drug to the base of pocket.
• Must have microbiologically effective concentrations in the pocket.
• Should sustain the concentration of the drug in the pocket for sufficient period of time & at a
concentration to be clinically effective.
• Less undesirable side effects. (Goodson 1985)
21. VARIOUS DRUG DELIVERY DEVICES :
FIBERS
• FILMS
• INJECTABLE GELS
• STRIPS AND COMPACTS
• VESICULAR LIPOSOMAL SYSTEMS
• MICROPARTICLE SYSTEM
• NANOPARTICLE SYSTEM
22. Fibers
• Fibers, or thread-like devices, are reservoir-type systems, placed circumferentially into the
pockets with an applicator and secured with an adhesive for the sustained release of the trapped
drug into the periodontal pocket.
• -2 types..
• hollow- reserviours without rate control system- drug release--- diffusion.
Eg: tetracycline in hollow fibres of cellulose acetate. (1979)
23. Fibers
• Monolithic- controlled dug release.
-- monolithic fibres of EVA with 25% tetracycline HCl.
Several polymers… Polyethylene, Polypropylene, Polycaprolactone, Polyurethane, Cellulose
acetate propionate and Ethylene vinyl acetate (EVA) have been investigated as matrices for LDD.
Eg: Chlorhexidine fibres, tetracycline fibres.
24. Films
• Films are matrix delivery systems in which drugs are distributed throughout the polymer and
release occurs by drug diffusion and/or matrix dissolution or erosion.
• Bigger films could be applied within the cavity onto the cheek mucosa or gingival surface
25. Both degradable and non- degradable films are available.
Advantages-
• Could be cut or punched into appropriate sizes so as to be inserted into the site of action.
• Can be easily inserted
• Minimal discomfort to the patient
• Sufficient adhesiveness is present
Non degradable films.. -- Addy et al., (1982) described the film or slab form intrapocket delivery
devices. They described the use of slabs of – made of methyl methacrylate for the intrapocket delivery of
tetracycline, metronidazole, chlorhexidine .
- degradable devices -- Periochip -- controlled subgingival delivery of chlorhexidine.
26. Injectable System
• It is relatively simple procedure.
• fluid nature of the formulations would allow the drug to gain access to the entire pocket.
• The application can be easily and rapidly carried out, without pain, by using a syringe.
• The formulation undergo a change in to a sticky semisolid or solid phase so as to prevent it from being
washed out.
27. • A higher biocompatibility and bioadhesivity, allowing adhesion to the mucosa in the dental
pocket.
• They can be rapidly eliminated through normal catabolic pathways, decreasing the risk of
irritative or allergic host reactions at the application site.
• Eg: gel formulations of tetracycline (2.5%), metronidazole (25%), metronidazole benzoate (40%),
combination of tetracycline (2.5%) and metronidazole benzoate (40%).
28. Strips and Compacts
• Acrylic strips have been fabricated using a mixture of polymers, monomers and different
concentrations of antimicrobial agents.
• Strips containing tetracycline, metronidazole or chlorhexidine demonstrated a decrease in number
of motile rods, notably spirochetes.
• In a later development, the evaluation of amoxycillin-clavulanic acid loaded acrylic strips is
reported.
29. • Highest level of antibacterial agent was released during the first 24 hours period followed by
release of therapeutic level of drugs for a subsequent 9 days period.
• Effect persisted even after 3 week of removal of acrylic strips.
• Tissue adhesive implants were made using n-butyl-2-cyanoacrylate as a drug trapping material
and slowly release drug when used in the form of a biodegradable local drug delivery device.
30. Vesicular Systems
• Designed to mimic the bio-membranes in terms of structure and biobehaviour, and hence are
investigated intensively for targeting periodontal biofilms.
31. • The targeting of liposomes was thought to be because of the interaction of the polyhydroxy
groups of liposomes with surface polymers of the bacterial glycol-calyx.
• Proteoliposomes (Succinylated Concanavalin-A (lectin)-bearing liposomes)have been found to be effective
for the delivery of triclosan to periodontal biofilms.
• Studies.. Even after a very short exposure, liposomes were retained in the bacteria delivering the
drug into cellular interiors. (Robinson et al.)
32. Microparticle System
• Non-biodegradable and biodegradable materials for the preparation of microspheres include the
polymers of natural origin, modified natural substances and synthetic polymers.
• Biodegradable polymers such as poly lactide (PLA) or poly (lactide – co-glycolide) PLGA has been
designed for periodontal disease therapy.
33. • PLGA microspheres containing minocycline … have been used for the elimination of
Porphyromonas gingivalis from the periodontal pocket.
• .. provide stability to the encapsulated drug.
• The in vitro drug release in these systems depends upon the polymer (lactide:glycolide) ratio,
molecular weight, crystallinity and pH of the medium.
34. Nanoparticle System
• The nanoparticulate system provides several advantages as compared with microspheres,
microparticles and emulsion-based delivery systems, including high dispersibility in an aqueous
medium, controlled release rate and increased stability.
• Penetrate regions that may be inaccessible to other delivery systems, such as the periodontal pocket
areas below the gum line
35. • These systems
• Reduce the frequency of administration and
• Provide a uniform distribution of the active agent over an extended period of time.
• Biocompatible nanoparticles composed of 2-hydroxyethyl methacrylate (HEMA) and
polyethyleneglycol dimethacrylate (PEGDMA) could be used as a drug delivery system
for dental applications.
36. • Three preliminary studies -- assess the efficacy of nanoparticles in periodontal drug delivery.
a) Antisense oligonucleotide- loaded chitosan tripolyphosphate (TPP) nanoparticles and showed the
sustained release of oligonucleotides which is suitable for the local therapeutic application in
periodontal diseases. (Dung et al.)
b) An in vivo study in dogs with induced periodontal defects using Triclosan-loaded polymeric
(PLGA, PLA and cellulose acetate phthalate) nanoparticles and suggested that triclosan-loaded
nanoparticles penetrate through the junctional epithelium. (Pinon et al)
37. ) the in vitro bactericidal activity of the Harungana madagascariensis leaf extract (HLE) on the
oral bacterial strains largely implicated in dental caries and gingivitis infections. Moulari et. Al.
• Incorporation of the HLE into a colloidal carrier improved its antibacterial performance and
diminution of the bactericidal concentration was observed.
39. TETRACYCLINE
• Tetracycline is a bacteriostatic antibiotic that interferes with bacterial protein synthesis and inhibits
tissue collagenase activity.
• Agents used commonly are: Tetracycline HCl, Doxycycline HCl, Minocycline HCl
• Goodson et al in 1979 first proposed the concept of controlled delivery in the treatment of
periodontitis.
• The first delivery devices involved hollow fibers of cellulose acetate filled with tetracycline.
40. Tetracycline –containing fibers(Actisite)
• FDA approved.
• Non resorbable, biologically inert, safe polymer (ethylene vinyl acetate) loaded with 25% w/w
tetracycline HCl powder.
• packed as flexible yellow fibres of 0.5mm d, 23cm length (2.7 mg TTC).
• maintains constant concentrations of active drug in the crevicular fluid in excess of 1000 μg/mL for a
period of 10 days Maurizio S etal)
• In contrast GCF conc. of only 4-8 microgram/ml were reported after systemic administration, 250 mg
qid for 10 days.
41.
42. • In a 60-day multicenter study - 107 periodontitis patients after supragingival scaling,…
• Four non-adjacent teeth (pockets in the range of 6-10mm) was selected and randomly assigned to 4 groups-
Tetracycline fiber, Placebo fiber, Scaling and Untreated.
• Results-fiber therapy significantly had reduction in probing depth, BOP,and gain in attachment levels.
Goodson et al )
• … study in periodontal maintenance patients needing treatment of localized recurrent periodontitis…Effect
of fiber therapy was evaluated as an adjunct to SRP.
• Results – sites treated with fiber and SRP showed significantly higher attachment level, pocket depth
reduction and less BOP (Newman et al (1994)
.
43. • Other forms:
• Bioresorbable form is PERIODONTAL PLUS AB
• formulation containing TTC (2 mg of Tetracycline) in 25 mg of collagen fibrils.
• dual mode of action by…...
• enables the active agent and vehicle to be able to work positively towards the repair of the
periodontal lesion.
• Each vial contains 25 mg (Total 100 mg in 4 vials)
44. • Tetracycline-Serratiopeptidase-Containing Periodontal Gel
• Study- - Serratiopeptidase tetra gel with aerosol (colloidal silica) used.
• ….Aimed to decrease polymer concentration and to obtain reasonable vicocity at a lower
concentration of pluronic gel by adding a viscocity modifier.
• Results…- Formulation has shown statistically significant results along with scaling and root
planing(Maheshwa ri etal)
45. author LDD agent results conclusion
Singh et
al.(2009)- 3
months -
TTC impregnated
collagen fibres.
No difference in the results achieved
with local tetracycline hydrochloride or
local metronidazole as adjuncts to
mechanotherapy
Both resulted in greater
antibiotic therapies
improvement in
microbiological parameters
when compared to
mechanotherapy alone.
Sadaf et
al.(2012)-3
months
.
Tetracycline fibers- Higher reduction in plaque index, gingival
index and in the clinical probing depths of
the tested group than of the control group
at all time intervals -15, 30, 60 and 90
days.
Effective as adjunct to
SRP.
Gupta et al.2015 TTC impregnated
collagen fibres.
more reduction in clinical parameters
(PD,GI, PI) compared to control
Tetracycline fiber therapy
enhances the benefits of
SRP in the treatment of
chronic periodontitis
STUDIES
46. SUBGINGIVAL DOXYCYCLINE
• broad-spectrum antibiotic
• bacteriostatic, inhibiting bacterial protein synthesis
• ability to downregulate MMPs.
• The only FDA approved 10% Doxycycline – ATRIDOX gel (42.5 mg Doxycycline)
• Subgingival controlled-release product composed of a 2 syringe mixing system.
47. 49
• 2 syringe mixing system
• Syringe A -- 450 mg of the ATRIGEL® Delivery
System, which is a bioabsorbable, flowable polymeric
formulation.
• Syringe B- doxycycline hyclate which is equivalent to
42.5 mg doxycycline.
48. • The constituted product is a pale yellow to yellow viscous liquid with a concentration of 10% of
doxycycline hyclate.
Upon contact with the crevicular fluid, the liquid product solidifies and quickly hardens to a wax-
like substance, then allows for controlled release of drug for a period of 7 days.
49. Doxycycline levels in GCF Time
1,500 - 2000 μg/mL 2 hours
> 1000 μg/mL 18 hours
Well above the minimum inhibitory
concentration for
periodontal pathogens (6.0 μg/mL)
Day 7
95% of the polymer is bio absorbed or
expelled from the pocket
naturally
Day 28
(Polson AM, 1997
50. author Results and conclusion
Garrett ,2003 - Atridox was compared to placebo
control and oral hygiene and SRP…. In
411 pts with moderate to severe adult
periodontitis.
Treatment to be statistically superior to placebo
control and oral hygiene and equally effective as
SRP.
Machion L et al. 2006.
evaluated the association of locally
delivered doxycycline 10% in the
periodontal treatment of smokers(2 yrs)
Reduction in clinical parameters…use of
locally delivered doxycycline may constitute an
important adjunct for the active and supportive
treatments of severe periodontal disease in
smokers.
Deo et al.(2011)- Doxycycline hyclate 10% as an adjunct
to SRP (6 months) -
significant reductions in PPD and gains in
CAL compared to SRP alone.
STUDIES
51. SUBGINGIVAL MINOCYCLINE
• Semisynthetic tetracycline - first introduced in 1967
• in vitro antibacterial activity against a wide range of gram-ve and gram+ve
microorganisms
• LDD minocycline -- tried clinically via in three different modes i.e. film, microspheres,
and ointment.
1. Film:
• Ethyl cellulose film containing 30% of Minocycline were tested as sustained release
• complete eradication of pathogenic flora from the pocket after 14 days.
52. Microsphere:
• Locally delivered, sustained release form of minocycline microspheres (ARESTIN) for subgingival
placement is available.
• Arestin-- 2% minocycline encapsulated into bio-resorbable microspheres (20-60μm in diameter) in
a gel carrier and has resorption time of 21 days.
• Gingival crevicular fluid hydrolyses the polymer and releases minocycline for a period of 14 days or
longer before resorbing completely.
53. Electron photomicrograph and CS view
of microsphere showing minocycline
HCL particles
The microspheres is dispensed
subgingivally to the base of the
periodontal pocket by means of a
disposable plastic cartridge affixed to a
stainless-steel handle .
54. Ointment:
• 2% minocycline hydrochloride in a matrix of hydroxyethyl-cellulose, aminoalkyl-methacrylate,
triacetine & glycerine.
• DENTOMYCIN –European union
• PERIOCLINE -JAPAN
• The concentration of minocycline in the periodontal pocket is about 1300μg/ml, 1 hr after
single topical application of 0.05 ml ointment (1mg of minocycline) and is reduced to 90μg/ml
after 7 hrs.
55. The Dentomycin gel has been reported to be effective in periodontal disease because of:
• Its power to eliminate key periodontal pathogens.
• Minimal risk of bacterial resistance.
• Inhibits harmful bacterial collagenase without effecting normal collagen turnover and regeneration of
gingival tissues.
56. author Results and conclusion
Van
Steenberghe et
al.1993
–- 103 adults with moderate to severe periodontitis… SRP
done at baseline
Patients received either the test or a control minocycline
ointment (dentomycin gel) in four sessions at an interval
of 4 weeks.
– a significantly greater reduction of PD in test
group- Treatment to be statistically superior to
control
.
Steenberghe et
al (1999)
Locally administered minocycline microspheres-–
multicenter trial -748 pts with moderate to advanced
periodontitis. -
combined therapy provided a better result than
SRP alone at sites >7 mm deep... Results – test
sites showed significantly more PD reduction
than either SRP alone.
Jung et al.(
2012)
Minocycline hydrochloride2% - Reductions in PPD, BOP and gain in CAL were
significantly greater at the minocycline
ointment in association with flap surgery site
than at the flap surgery site alone.
Pandit N , et
al,2013)
A randomized, controlled, study.. to evaluate and
compare the efficacy of subgingivally delivered
Minocycline microspheres and 25% Metronidazole gel
when used as an adjunct to SRP
that treatment with Minocycline microspheres
and Metronidazole gel improve PPD and CAL in
patients with periodontitis compared to SRP
alone.
STUDIES
57. SUBGINGIVAL METRONIDAZOLE
• Metronidazole is particularly attractive as an antimicrobial because of its selective efficacy against
obligate anaerobes.
• Both systemic and local applications are effective against periodontal pathogens.
• Metronidazole has been incorporated as collagen sponges, dialysis tubing, acrylic strips, films and gel
forms for sustained subgingival delivery in the treatment of periodontal disease.
58. Elyzol
• metronidazole 25% in a mixture of glyceryl mono-oleate and sesame oil.
Contains metronidazole benzoate- active agent.
• flows freely on application.. on contact with gingival crevicular fluid, becomes more viscous and
stays in the periodontal pocket… gel disintegrates in the pocket and releases metronidazole.
• for at least 24 hours.
• Can be administered quickly and easily and high periodontal pocket levels of metronidazole are
maintained.
• Administered twice- with an interval of one week.
59. author Results and conclusion
Ainamo et al
1992
– two randomly selected quadrants were treated with the
gel twice a week; other two – 2 episodes of subgingival
scaling.
.
No significant differences.
. Pedrazolli et
al 1992 (6-
month)
microbiological outcome of 2 gel applications vs scaling
was compared.
total bacterial cultivable count and proportions of
anaerobic bacteria were affected in a similar way
in both groups, and no difference was seen in PD
reduction & BOP.
Griffiths et
al.(2000)-
-9 months-Metronidazole 25% dental gel. -Combined therapy of SRP and metronidazole
25% dental gel was superior to the conventional
treatment of SRP alone
STUDIES
60. CHLORHEXIDINE
• Available as mouthrinses, Gels, varnishes, and chip to be used as a local drug delivery agent .
MECHANISM OF ACTION (Rolla and Melsen)
• By binding to anionic acid groups on salivary glycoproteins thus reducing pellicle formation and
plaque colonization.
• By binding to salivary bacteria and interfering with their adsorption to teeth.
61. • Chlorhexidine has been shown to be an effective agent in plaque inhibition (Loe et al 1976)
as…
• well retained in the oral cavity,
• Reacting reversibly with receptors in the mouth due to its affinity for hydroxyapetite and
acidic salivary protein.
• Its antibacterial action is due to an increase of the cellular membrane permeability followed by
the coagulation of intracellular cytoplasmic macromolecule.
62. • Periochip:
• small chip (4.5× 3.5mm) composed of biodegradable hydrolyzed gelatin matrix, crosslinked
with glutaraldehyde, also contains glycerine &water into which chlorhexidine gluconate
(2.5mg) is incorporated.
• Perio Chip releases chlorhexidine in vitro in a biphasic manner,
• Initially releasing approximately 40% of the chlorhexidine within the first 24 hours, and then
releasing the remaining chlorhexidine in an almost linear fashion for 7–10 days.
63. • Unique patented “targeted controlled
release” bio degradable polymer
containing chlorhexidine.
• Small, bullet-shaped or baby’s finger
nail like thin film, weighing 7.4mg.
64. • Insertion of a chlorhexidine chip into a residual pocket mesial to an upper molar with a
furcation involvement.
65. • 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.
66. Chlosite application
• Chlo-Site is an agent containing 1.5% chlorhexidine of
xanthan type .
•Xanthan gel is a saccharide polymer, which constitutes of a
three-dimensional mesh mechanism, which is biocompatible
with chlorhexidine.
67. author Results and conclusion
Soskolne et al
1997, Jeffcoat
et al 1998
split mouth design to compare the treatment outcomes of
SRP alone with the combined use of SRP & PerioChip in
pocket depth of 5-8mm.
– average PD reduction in treated sites with
chip was significantly greater than in the sites
receiving mechanical treatment only.
. Grover et
al.(2011)
3 months -Chlorhexidine chip and SRP. .
resulted in a clinically significant improvement
in PPD and CAL compared with SRP alone.
Medaiah et
al.(2014 - 3 months-Biodegradable chlorhexidine chip-
No statistically significant differences between
SRP and SRP + CHIP group in all clinical
parameters
STUDIES
68. STUDIES
• Meta-analysis on four studies including SRP and local sustained release agents compared with SRP
alone….
Results …when SRP is combined with certain antiinfective agents in sustained release vehicles,
statistically significant adjunctive effects on PD reduction and a decreased percentage of sites with BOP
can be anticipated. Statistically significant effects of PD reduction were seen with CHX chip.
• Compared with SRP alone, no evidence was found for the adjunctive effects on reduction of PI with
ATRIDOX and MINO microspheres. BOP reductions were not significant with ATRIDOX and TET
fibres.
• large effect of adjunctive therapy in pocket depth reduction, with a moderate effect on reduction of
bleeding scores and mild effect on reduction of plaque scores.
69. NEWER TRENDS IN LOCAL DRUG DELIVERY
• DRUGS FOR OSSEOUS DEFECTS
• Alendronate
• - a novel bisphosphonate; 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)
70. • Statins– Simvastatin, Atorvastatin, Rosuvastatin –
• Lipid lowering drugs-- an effective approach for the treatment of hyperlipidemia and
arteriosclerosis.
• Statins are specific competitive inhibitors of HMG-CoA reductase.
• modulate bone formation by increasing the expression of bone morphogenetic protein-2,
inflammation, and angiogenesis.
71. author Results and conclusion
Pradeep et al,
2010
Effect of locally delivered SMV gel as LDD in patients
with chronic periodontitis.
– 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
to investigate the effectiveness of 1.2%
ATV(Atorvastatin) as an adjunct to scaling and root
planing (SRP) in the treatment of intrabony defects.
Reduction in PD, CAL gain and greater mean
percentage of radiographic bonefill … ATV as
an adjunct to SRP can provide a new direction
in the management of IBDs.
STUDIES
72. author Results and conclusion
(AR Pradeep,
2015)
clinical effectiveness of subgingivally delivered 1.2%
rosuvastatin (RSV) gel incorporated into a
methylcellulose vehicle for its controlled release into
intrabony defect (IBD) sites as an adjunct to scaling and
root planing (SRP) for treatment of patients with CP
Rosuvastatin in situ gel (1.2%) as LDD--
greater reduction than placebo in PD and
gingival index, along with increased gain in
CAL
AR Pradeep,
2016)
To evaluate and compare the efficacy of 1.2% RSV and
1.2% ATV gel local drug delivery (LDD), in addition to
scaling and root planing (SRP), for the treatment of
intrabony defects (IBDs) in patients with chronic
periodontitis (CP
)…..LDD of 1.2% RSV results in significantly
greater clinico-radiographic improvement than
1.2% ATV or placebo gels as adjunct to
mechanical periodontal therapy.
STUDIES
73. • Metformin
• --effectiveness of MF 1% in an indigenously prepared, biodegradable, controlled-release gel, as an
adjunct to scaling and root planing (SRP) in treatment of vertical defects in smokers with
generalized chronic periodontitis (CP) was investigated….greater decrease in mSBI and PD and
more CAL gain with significant IBD fill at vertical defect sites treated with SRP plus locally
delivered MF, versus SRP plus placebo, in smokers with generalized CP. (Rao. NS et al, 2013)
74. Satranidazole: ,Study.. effectiveness of subgingivally delivered satranidazole (SZ) gel as an adjunct
to scaling and root planing (SRP) in the treatment of chronic periodontitis.
Results….greater mean reduction of PD, mean CAL gain and number of sites harboring
periodontopathogens…. The use of 3% SZ gel, when used as an adjunct to nonsurgical periodontal
therapy in subjects with periodontitis, achieved better results than initial periodontal treatment alone.
(N Priyanka, 2015)
75. Clarithromycin gel
Clarithromycin has been used in periodontal treatment as an adjunct to SRP in gel form as LDD.
Study-- investigate the adjunctive effects of subgingivally delivered 0.5% clarithromycin (CLM)
as an adjunct to scaling and root planing for treating chronic periodontitis in smokers.
Adjunctive use of 0.5% clarithromycin as a controlled drug delivery system …enhanced the
clinical outcome in smokers (Agarwal E etal, 2012.).
77. • Eucalyptus extract
• Ethanol extracts (60% ethanol) from Euclyptus globulus leaves reportedly possess
antibacterial activity against various bacteria, including oral bacteria.
• displayed antibacterial activity against several periodontopathic bacteria, (Porphyromonas
gingivalis and Prevotella intermedia)
• The growth of P. gingivalis was strongly inhibited even with a low concentration (10 mg/ml)
of eucalyptus extracts.
78. • A double masked study revealed that subjects who chewed eucalyptus containing gum found
relief from the disease's symptoms-- lesser gingival bleeding, reduction in pocket depth and
reduced plaque accumulation. Using toothpaste or tinctures containing eucalyptus extract
could benefit the periodontal condition. Nagata H.,2008.
79. Neem
• Neem leaf extract can help reduce bacteria and plaque levels that cause the progression of
periodontitis.
• bioactive materials found in neem leads to the presence of gallotannins during the early stages of
plaque formation that could effectively reduce the number of bacteria available for binding to the
tooth surface by increasing their physical removal from the oral cavity through aggregate
formation.
• potential anti-plaque activity -- reduced bacterial adhesion to saliva coated hydroxyapetite.
80. • A study was done to evaluate the effectiveness of neem (Azadirachta indica) leaf extract against
plaque formation in males between the age group of 20–30 years over a period of 6 weeks. The
results of the study suggested that the gel containing neem extract has significantly reduced the
plaque index and bacterial count than that of the control group (Wolinky LE et al.)
81. Bloodroot
• Sanguinaria canadensis (bloodroot) -- herbaceous flowering plant native to eastern North
America.
• The FDA has approved the inclusion of sanguinarine in toothpastes as an antibacterial or
anti-plaque agent.
• Due to its natural alkaloids, bloodroot can curb the growth of bacteria responsible for
periodontal disease.
• reduce inflammation and prevent deepening of periodontal pockets, thereby preventing bone
loss & tooth loss.(Reddy PD, 2010)
82. • Chamomile (Matricaria Recutita)
• an age-old medicinal herb known in ancient Egypt, Greece and which are a member of the
Asteraceae family.
• With its anti-inflammatory and antibacterial properties, chamomile helps in reducing the
inflammation in periodontal tissues and reduces the bacterial load in the oral cavity. (Reddy PD,
Chopra RN et al)
83. Liquorice
• Liquorice (Glycyrrhiza glabra),-- sweet wood (native to the Mediterranean and certain areas of
Asia).
• a perennial herb with sweet taste; widespread pharmacological effects.
• The most common medical use of liquorice is for treating upper respiratory infections including
coughs, hoarseness, sore throat and bronchitis. (Söderling E, Sasakia H)
84. • antioxidant and hepatoprotective properties… inhibit the generation of reactive oxygen
species (ROS) by neutrophils at the site of inflammation. (Racková L)
• The ability of liquorice to reduce formation of dental plaque contributes to its role in
periodontitis management.
85. Propolis
• generic name for a complex resinous mixture collected by honey bee from the buds and exudates of various
plants.
• used for the treatment of aphthous ulcer, Candidiasis, gingivitis, periodontitis, and pulpitis due to its
antimicrobial and anti- inflammatory activities.
• Studies have evaluated the antibacterial action of propolis against certain anaerobic oral pathogens and found it
to be very effective against Peptostreptococcus anaerobius, Lactobacillus acidophilus, Actinomyces naeslundii,
Prevotella sp., Porphyromonas gingivalis, Fusobacterium nucleatum and Veillonella parvula. (Gebara EC)
86. A study was aimed at the clinical and microbiological evaluation of the efficacy of subgingivally
delivered Indian propolis extract as an adjunct to scaling and root planing (SRP) in the treatment of
periodontitis. Twenty patients diagnosed with chronic periodontitis presenting a minimum of two pockets (probing depth
≥5 mm) were selected. Sites were assigned randomly into control sites (n=20) which received SRP alone or test sites (n=20)
which received SRP and locally delivered propolis. At selected sites, the clinical parameters were assessed and subgingival
plaque samples were collected at baseline, 15 days and one month. The samples were cultured 76 anerobically for
periodontal pathogens. The results indicated that there was a significant improvement in both clinical and microbiological
parameters (p<0.01) in the test sites compared to the control sites at the end of the study. Subgingival delivery of
propolis showed promising results as an adjunct to SRP in patients with chronic periodontitis when
assessed by clinical and microbiological parameters.
87. • The medicinal value of the plant lies in a gel-like pulp obtained on peeling the leaves.
• These substances include …. Lignins, Saponins, Vitamins, aminoacids, anthraquinones etc..
• improves wound healing by
• Increasing blood supply, which increased oxygenation as a result.
• potent free radical and superoxide anion scavenging properties. (Yagi et al. in 2002 )
88. STUDIES:
• Aim : To evaluate the effect of aloe vera gel as an adjunct to scaling and root planing (SRP) in the
management of chronic periodontitis.
• SRP-ALOE group showed significantly better results than SRP alone. (Harjit Kaur ,2012)
• Geeta Bhat et al, 2011) in her study concluded that its use in local drug delivery results in significant
reduction in pocket depth and resulted in reduction in the gingival index.
89. • It has proven properties like
• Anti-inflammatory, antioxidant, antimicrobial, hepatoprotective, antiseptic, accelerates wound
healing.
• study … evaluate the adjunctive efficacy of turmeric, curcumin, and traditional nonsurgical
methods for treating periodontal pockets.
• Plaque index and gingival index scores showed significant improvement from baseline through
the end of the study. Kudva P et al,2012
90. • 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. (Roobal Behal et al. 2011)
91. • A clinical study conducted by Sastracaha et al (2003) concluded that extracts of Punica granatum plus
scaling and root planning significantly reduced the clinical signs of chronic periodontitis.
• Vasconcelos et al (2006) investigated the antimicrobial effect of Punica granatum Linn
(pomegranate) phytotherapeutic gel and concluded that Punica granatum L. gel had greater efficiency
in inhibiting microbial adherence in oral cavity.
92. HERBAL COMBINATIONS
• Along with individual herbs, herbal combinations can combat periodontitis.
• Mixture of peppermint oil, menthol, chamomile, clove oil.. can reduce periodontitis symptoms.
World Journal of Pharmaceutical Research Vol 3, Issue 2, 2014.
93. LOCAL DELIVERY OF GROWTH FACTORS
• Fibroblast growth factor was found to 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 growthfactor (bFGF) in a
controlled-release system was developed.(Nakahara T et al.2003)
94. • NOVEL CHITOSAN-PVA-BASED LOCAL DELIVERY
• Chitosan is a natural polysaccharide.
• ..physically or chemically crosslinked to prepare microspheres, films and gels.
• These stable chitosan-based depot systems have been investigated for treatment of various diseases
including cancer and bacterial infection.
• Localized drug delivery system with chitosan and poly vinyl alcohol (PVA) for treating severe
periodontitis has been designed that delivered antibacterial agent ornidazole into gingival crevicular
fluid. (Wang LC etal) …
95. • As a monotherapy, LDDsystems incorporating a variety of drugs can improve periodontal health.
• There is no single universal drug that would be effective in all situations. Therefore, at non-responsive sites,
bacterial and antibiotic sensitivity testing may be necessary to determine putative pathogens and their
susceptibility to specific antimicrobial agents.
• LDD often appears to be as effective as scaling and root planing with regards to reducing signs of periodontal
inflammatory disease.
• Local delivery may be an adjunct to conventionaltherapy. The sites most likely to be responsive to this
adjunctive treatment method may have refractory or recurrent periodontitis, or specific locations where it is
difficult o instrument root surfaces.
SUMMARY
96. 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.
• Mechanical instrumentation, can be technically demanding, time consuming, and in some
periodontal defects, ineffective or incomplete.
• LDD on the other hand is simple to use and may conceivably in the future be delivered by the
patient themselves, hence can be used as an adjunct to mechanical plaque removal.
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of Dental and Medical Sciences (IOSR-JDMS)
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