Much discussion and research has gone on regarding the benefits of the local application of medications into the infected periodontal pocket. Most researchers as well as clinicians believe that without concurrent root debridement via scaling and root planing or ultrasonic debridement (non-surgical therapy), most antimicrobials have only a very transient effect. Various chemicals have been used in the treatment of periodontal disease. These include chlorhexidine gluconate, tetracycline, saline (salt water) as well as other antibiotics, to name a few. Most of these chemicals can be injected into the periodontal pocket after root debridement. These chemicals act to flush out the pocket as well as leave some antimicrobial, which hopefully continues to kill any residual bacteria left behind. There are new resorbable carriers (either gels, polymers, or cellulose acetate) which keep the drug in the pocket at increased concentrations. These medications may be helpful in the management of problematic sites with ongoing or recurrent disease, but do not appear to provide a "silver bullet" permanent solution. In addition, no local delivery system has long-term clinical research (most studies are no longer than 8 months). And while there appears to be a place for these modalities in the care of many periodontal patients, many questions have still not been answered. An example of a new generation of locally delivered antimicrobial used in Dr. Zablotsky's practice is Atridox.
Atridox provides the controlled-release of 42.5 mg doxycycline under the gums. Doxycycline is a broad spectrum semisynthetic tetracycline that kills bacteria associated with periodontal disease. Atridox uses the Atrigel Delivery System, a nonsurgical, bioresorbable method of delivering anti-microbial therapy.
Atridox is available for site-specific treatment of adult periodontal disease. It is applied in fluid form directly into periodontal pockets using a syringe. Once in the pockets, the Atridox fluid solidifies, releasing doxycycline for approximately one week. During this period, tooth brushing and flossing should be avoided. Since Atridox is biodegradable, it does not require removal. Many sites can be treated with one syringe of this material.
Atridox offers the potential for results at least 75% as effective as scaling and root planing in pockets measuring 5 mm or greater. Due to concerns regarding antibiotic resistance, antibiotic-based products such as Atridox are best reserved for problems that are non-responsive to conventional therapy. Click here for more information regarding Block Drug Systemic antibiotics/antimicrobials in the treatment of periodontal diseases.
It may be advantageous in some cases to consider the use of systemic antibiotics to help in the management of periodontal diseases. Some forms of the disease, i.e. juvenile periodontitis which effects adolescents, must be treated with antibiotics to adequately eradicate the infection in the pocket and gum tissues, as non-surgical treatment alone will not disinfect the affected areas. Studies show that targeted antibiotic therapy, especially for patients who are resistent/refractory to conventional treatment may be very beneficial. A University of Michigan study by Loesche and one by Kwan in a private practice setting have shown that local debridement (with either hand scaling and root planing or microultrasonic debridement) in conjunction with the prescriptive drug Flagyl (generic for metronidizole), good personal oral hygiene, and close 3 month supportive periodontal care are effective at controlling the periodontal infection for long periods of time.
Host modulating medications
Until only recently the dental profession could only use chemicals to target and kill the bacteria which cause gum disease. Since up to 75% of the destruction of the gum tissues occurs from the patient's immune system's response to the presence of bacteria and their toxins, researchers have been trying to find a way to block the inflammatory pathway so that the immune system cannot cause as much damage even if periodontal disease inducing bacteria are present.
Periostat taken systemically twice a day for up to 9 months contains 20 mg of doxycycline hyclate per dose and acts as a collagenase inhibitor. Collagen is the building block protein which gives the gums their strength. In order for gum disease to progress it is necessary to break down collagen. The enzyme collagenase performs this function. Bacteria as well as many host cells in the gums can release this enzyme. Periostat selectively blocks only the collagenase responsible for the breakdown of collagen associated with periodontal disease. You may be aware that doxycycline is an antibiotic, and that 9 months is a long time to take an antibiotic due to the potential for drug resistance and other long-term side effects.
While these concerns would normally be valid, these problems are not seen due to the very low dose of doxycycline. At the therapeutic dose of 40mg per day this drug does not kill bacteria or effect the resident microflora of the body.
Periostat is used in conjunction with scaling and root planing or for supportive periodontal care/maintenance patients showing continuing breakdown. Taken twice per day, its properties reduce the elevated collagenase activity in the gingival crevicular fluid. At this time, it is only intended for use in patients with adult periodontal disease.
Since long-term studies are not available concerning the stability of the results obtained with these new chemotherapeutic modalities, patients require close monitoring following their therapy. The American Academy of Periodontology (AAP) has stressed that "all new technologies must be carefully assessed in controlled longitudinal studies, and should show added value over current conventional technologies prior to adoption for routine use."