Quality Resource Guide
l
Local Delivery of Agents to Treat Periodontal Diseases 4th Edition
5
www.metdental.com
SRP, baseline measurements were made followed
by implant debridement. Measurements and chips
placement were repeated at weeks 2, 4, 6, 8, 12 and
18 in sites where probing depths were ≥6mm. At
6 months, patients returned for final examination.
The results of the study showed a reduction in
probing depth 0.6mm greater than controls (p=0.07).
Up to 70% of the sites had a probing depth reduction
≥2mm compared to 40% in the control group. BOP
was reduced by 50% in both the experimental and
control groups.
34
In addition to benefits seen from use
of chlorhexidine containing chips, administration of a
1% chlorhexidine gel has shown some improvement
in peri-implant mucositis.
35
Interestingly, in a recent study to treat failing
implants, the authors combined irrigation with
Chlorhexidine and local delivery of minocycline
HCl and found significant clinical and radiographic
improvements. While this study is an example
of
treatment
efficacy
by
combining
local
chemotherapeutic agents, it may be difficult
to ascertain if the resolution is truly from combination
of the drugs and not disproportionately from
one of the two agents.
36
Similarly, in another study,
minocycline application during maintenance phase
was compared to placebo after surgical treatment of
peri-implantitis. Statistically significant improvements
were noted clinically, radiographically and in
reduction of red complex microbiota. This study is a
departure from the conventional clinical use of locally
delivered antibiotics along with non-surgical therapy
and opens an interesting line of inquiry.
37
It is noteworthy that a Cochrane Review in 2012
stated that there was no reliable evidence suggesting
the most effective intervention for treating peri-
implantitis. However, they noted that, based on
limited data, in patients who lost at least 50% of
bone around implants, local delivery of antimicrobials
resulted in a reduction of PPD of 0.59mm.
35,38
Discussion
Scaling and root planing alone are effective in
reducing PD, CAL and BOP. When SRP is combined
with the subgingival placement of sustained-release
anti-infective agents, however, additional clinical
benefits are possible, including further reduction
in PD, and additional gain in CALs. Use of local
anti-infective treatment adjuncts does not appear
to cause significant adverse effects. However,
potential allergic reactions must be considered.
A patient allergic to tetracyclines should not receive
treatment with any tetracycline, including doxycycline
and minocycline. Similarly, patients allergic to
chlorhexidine cannot be medicated with locally
delivered chlorhexidine.
Cost of therapy is another factor to consider. The
cost of one syringe of doxycycline is ~$69.00. Since
one syringe can treat 4 pockets, the per pocket cost
averages ~$17.00. The cost to treat a pocket with
minocycline microspheres averages ~$25.00 and for
the chlorhexidine chip it averages ~$16.00.
Patients may require re-dosing with these agents
to obtain adequate pocket depth reduction. In the
studies under which the products were assessed for
FDA approval, doxycycline gel was used twice over
a period of 9 months. Minocycline microspheres
were used 3 times and the chlorhexidine chip up to
3 times over the same time period. It is the author’s
experience that, if these agents do not produce an
adequate clinical outcome after 3 applications (2 for
doxycycline gel), additional local delivery of an agent
may not be beneficial.
Studies in which SRP is combined with systemic
antibiotics demonstrate improvement in CALs and
reduction in PDs similar to those seen when locally
delivered agents are used as an adjunct.
38
Systemic
administration delivers the antibiotic to multiple sites,
Table 2 - Six-Month Studies of Mouthrinses
Product
# Studies
Efficacy
ADA
Accepted
% Plaque
% Gingivitis
Chlorhexidine 0.12%
6
Statistically significant for all
Yes*
29-51
22-34
Essential Oils
25**
Statistically significant for 16;
Non-significant for 9
Yes
19-56
15-27
Cetylpyridinium Chloride:
0.045-0.05%
0.07%
5
4
Statistically significant reduction only in plaque in
4 studies, non-significant in 1 study.
Statistically significant reduction in gingivitis in
3 studies, minimal reduction in plaque in 1 study.
No
No
10-28
0-9
15-24
22-26
Stannous Fluoride
5
One study shows statistically significant reduction
in plaque and gingivitis at 4 mos., but not after 4
mos. Other studies show little or no statistically
significant benefits.
No
0-25
0-22
*
Effective Jan 1st, 2008, ADA no longer placed its Seal of Acceptance on prescription (professional?) products.
**
Total equals 25 because 4 of the studies listed had 2 active arms