Retention, antimicrobial activity, and clinical outcomes following use of a bioerodible tetracycline gel in moderate-to-deep periodontal pockets

Supra and subgingival application of antiseptics or antibiotics during periodontal therapy

Periodontal diseases (gingivitis and periodontitis) are characterized by inflammatory processes which arise as a result of disruption of the balance in the oral ecosystem. According to the current S3 level clinical practice guidelines, therapy of patients with periodontitis involves a stepwise approach that includes the control of the patient's risk factors and the debridement of supra and subgingival biofilm. This debridement can be performed with or without the use of some adjuvant therapies, including physical or chemical agents, host modulating agents, subgingivally locally delivered antimicrobials, or systemic antimicrobials. Therefore, the main aim of this article is to review in a narrative manner the existing literature regarding the adjuvant application of local agents, either subgingivally delivered antibiotics and antiseptics or supragingivally applied rinses and dentifrices, during the different steps in periodontal therapy performed in Europe.

Sustained-release delivery of antimicrobial drugs for the treatment of periodontal diseases: Fantasy or already reality?

Periodontal diseases are prevalent in humans. Conventional means of combating these diseases involve basic oral hygiene, mostly toothbrushing, use of mouthwashes, and flossing. Supplementary means of treatment, either clinical or pharmaceutical, are often necessary. The use of sustained-release delivery systems, applied locally to the periodontal pocket, seems to be one feasible approach: local sustained-release delivery of antibacterial agents to treat periodontal diseases is conceivable. The use of local (intrapocket) sustained-release delivery systems has numerous clinical, pharmacologic, and toxicologic advantages over conventional treatments for periodontal diseases. Sustained-release technology has been proven to be effective over the last few decades. Films, gels, and fibers are the three main classical intrapocket pharmaceutical delivery systems. Research today is more focused on improving drug delivery, and less on introducing new drugs. New approaches, eg, those making use of nanotechnology, are emerging for local drug-delivery systems. The local sustained-release delivery system concept is innovative and a few products are already commercially available.

Amixicile, a novel strategy for targeting oral anaerobic pathogens

The oral microflora is composed of both health-promoting as well as disease-initiating bacteria. Many of the disease-initiating bacteria are anaerobic and include organisms such as Porphyromonas gingivalis, Prevotella intermedia, Fusobacterium nucleatum, and Tannerella forsythia. Here we investigated a novel therapeutic, amixicile, that targets pyruvate:ferredoxin oxidoreductase (PFOR), a major metabolic enzyme involved in energy generation through oxidative decarboxylation of pyruvate. PFOR is present in these anaerobic pathogenic bacteria and thus we hypothesized that amixicile would effectively inhibit their growth. In general, PFOR is present in all obligate anaerobic bacteria, while oral commensal aerobes, including aerotolerant ones, such as Streptococcus gordonii, use pyruvate dehydrogenase to decarboxylate pyruvate. Accordingly, we observed that growth of the PFOR-containing anaerobic periodontal pathogens, grown in both monospecies as well as multispecies broth cultures was inhibited in a dose-dependent manner while that of S. gordonii was unaffected. Furthermore, we also show that amixicile is effective against these pathogens grown as monospecies and multispecies biofilms. Finally, amixicile is the first selective therapeutic agent active against bacteria internalized by host cells. Together, the results show that amixicile is an effective inhibitor of oral anaerobic bacteria and as such, is a good candidate for treatment of periodontal diseases.

The Application of Microencapsulation Techniques in the Treatment of Endodontic and Periodontal Diseases

In the treatment of intracanal and periodontal infections, the local application of antibiotics and other therapeutic agents in the root canal or in periodontal pockets may be a promising approach to achieve sustained drug release, high antimicrobial activity and low systemic side effects. Microparticles made from biodegradable polymers have been reported to be an effective means of delivering antibacterial drugs in endodontic and periodontal therapy. The aim of this review article is to assess recent therapeutic strategies in which biocompatible microparticles are used for effective management of periodontal and endodontic diseases. In vitro and in vivo studies that have investigated the biocompatibility or efficacy of certain microparticle formulations and devices are presented. Future directions in the application of microencapsulation techniques in endodontic and periodontal therapies are discussed.

Formulation and preliminary in vivo dog studies of a novel drug delivery system for the treatment of periodontitis

A novel drug delivery system for the treatment of periodontitis was developed using two components. The first was tetracycline base loaded into the microtubular excipient halloysite, which was coated with chitosan to further retard drug release. Encapsulation efficiencies of 32.5% were achieved with the loading procedure, with tetracycline base showing in vitro release for up to 50 days in simulated gingival crevicular fluid. The second component developed was a vehicle for the drug loaded coated halloysite, which was primarily based on the thermoresponsive polymer, poloxamer 407. A concentration of 20% was chosen with the thermoresponsivity of the system modified using PEG 20,000 so that the mobile product at room temperature would gel by temperature rise following syringing into a periodontal pocket. Retention of the overall system in the pocket was further improved by the addition of octyl cyanoacrylate (OCA). The thermoresponsivity of the poloxamer 407 system proved to be sensitive to the presence of added excipients with the levels of PEG 20,000 and OCA requiring modification in the presence of the halloysite component. A final formulation was developed which consisted of 200 mg of halloysite double loaded with tetracycline base and coated with chitosan, suspended in 1 ml of poloxamer 407 20% (w/w), PEG 20,000 0.5% (w/w), OCA 1.0% (w/w), water to 100%, adjusted to pH 4. The syringeability of this formulation at various temperatures was evaluated to ensure ease of delivery to the periodontal pocket. A stability study was performed to examine the change in thermoresponsivity over time, with the final formulation found to be stable for at least 9 months when stored at room temperature (approximately 20 degrees C). This formulation offered ease of delivery to the periodontal pocket and sustained release of the antibiotic for up to 6 weeks. The formulation had preliminary in vivo testing performed in dogs to determine levels of drug release, antimicrobial activity and retentive ability of the product. A wound pocket creation model was developed for the purposes of the trial. The product was easy to deliver to the pockets with application times of less than 1 min. Results showed the product was retained in the pocket for up to 6 weeks with effective tetracycline levels released locally over this time period, which achieved good antibacterial activity.

Meta-analysis of local tetracycline in treating chronic periodontitis

BACKGROUND

Meta-analysis was used to assess the clinical efficacy of local delivery of tetracycline alone or as an adjunct to conventional mechanical therapy in patients with chronic periodontitis.

METHODS

Studies were identified in MEDLINE and others sources. Meta-analyses were performed on the basis of probing depth (PD) at baseline, type of antimicrobial used, and experimental and control regimens (i.e., tetracycline plus scaling and root planing [SRP] versus SRP, tetracycline versus SRP, and tetracycline versus placebo, or no treatment). The effect of local tetracycline was evaluated for follow-up times of 4, 8, 12, 16, 24, and 36 weeks. Sensitivity analysis was performed according to antimicrobial delivery mode (irrigation, fibers, strips). A random effects model was used.

RESULTS

The literature search identified 29 studies that met our inclusion criteria and were entered Into the meta-analysis. A significant mean reduction in PD for the combined tetracycline and SRP was observed regardless of initial probing depth and independently to the duration of follow-up. Tetracycline alone did not perform better than SRP, whereas they performed significantly better than placebo. Differences in improvement of attachment level (AL) were substantially similar to those encountered for PD.

CONCLUSIONS

Our results documented that local. delivery of tetracycline improves the clinical outcomes of traditional treatment and should be considered particularly as an adjunct to SRP. Considerations regarding the adverse effects of widespread use of tetracycline should be taken into account when choosing a therapeutic strategy of chronic periodontitis.

Periodontal therapy using local delivery of antimicrobial agents

Antimicrobial agents, systemic and/or local, are thought by some to be effective agents for treating periodontal infections. Here the authors determine the costs and benefits of local delivery agents for treating periodontal disease. Applying this cost-benefit analysis to patient care, however, will depend upon a clinician's expertise and a patient's value system.

A rapid spectrophotometric assay for tetracycline in gingival crevicular fluid

AIM

The aim of this study was to investigate a rapid spectrophotometric assay for its potential to measure tetracycline levels in gingival crevicular fluid (GCF).

MATERIALS AND METHODS

The technique involves complexation of tetracycline with molybdenum in order to shift the absorbance spectrum away from that region where interference with plasma proteins is a problem. The sensitivity of the assay and reproducibility of elution were examined together with an assessment of the effect of plasma proteins. The assay was also tested in a small pilot clinical project, measuring tetracycline levels in GCF following placement of a test gel formulation in 25 periodontal pockets in 5 patients.

RESULTS

The in vitro results showed good sensitivity of the assay over the concentration range tested (0.5-200 microg tetracycline) and with little effect of plasma proteins. Elution from the paper strips was reproducible with a good linear correlation between direct and filter absorbed assays (r=0.9989, p<0.01). The pilot clinical study indicated a mean half-time of tetracycline in GCF of 28 min with confidence intervals of 21 to 34 min, although wide variation between the drug levels of individual periodontal pockets was seen.

CONCLUSIONS

The results indicate good sensitivity for this assay to measure tetracycline hydrochloride in vivo. The potential for rapidly processing large numbers of samples contrasts with the assay time and limited sample throughput of other methods such as high pressure liquid chromatography (HPLC) and suggests that the technique may be a useful addition to current techniques for measuring tetracycline hydrochloride in vivo.