Pharmacology and Dentistry

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According to the American Academy of Periodontology (2004), has identified gingivitis as the inflammation of the gingiva that does not result in clinical attachment loss. Similarly, periodontitis is inflammation of the gingiva and the adjacent attachment structures and ultimately results in connective tissue attachment and alveolar bone loss and this disease state is causes connective tissue attachment and alveolar bone loss. Caregiivers and health professionals have outlined specific standards of assessment for periodontitis. Accordingly, the necessary steps of assessment include integrating a patient's medical history, dental history and periodontal risk factors. The most discriminating indicator of periodontitis is the presence of gram-negative, anaerobic bacteria, like Aggregatibacter actinomycetemcomitans and Porphyromonas gingivalis (Heitz-Mayfield 3) The presence of these types of bacteria competes with the normal flora within the mouth, teeth and gum line. As a result, the clinical indications of periodontal disease include the following factors such as probing depth (PD), bleeding on probing (BOP), clinical attachment level (CAL), degree of furcation involvement, extent of gingival recession, tooth mobility, and plaque score and the amount and location of bone loss (Sweeting, Davis, and Cobb 18). These probing depths are also interrelated to the extraoral and interoral structures and tissues of the patient. The assessment of teeth is also thorough with the primary focus of initial assessments dedicated to mobility patterns that would indicate occlusions, inflammation and potential loss of bone, caries and furcation involvement.

The diagnostic and planning phases for a patient's treatment plan is correlated to soft tissue assessment and periodontal risk factors. The clinical presentation of periodontitis requires that tissues must be evaluated for qualitative factors such color, contour, and keratinization. The probing of the depth, or PD, from the gingival margin and of the periodontal pocket will indicate the presence of the pathogenic bacteria. If this probing depth is more than 3 mm, then the affected tissue is used to select final periodontal treatment and management. Additionally, any sort of bleeding upon probing would indicate the inflammation of the gingiva, as any increase in bleeding increases the likelihood of disease progression (Sweeting, Davis, and Cobb 18)
Finally, soft tissue assessment locating any gingival recessions and evaluating clinical attachment levels, or CAL, to calculate the total amount of CAL. Outside of any of these quantitative findings, patients should be evaluated for their risk factors. Studies have focused on age, gender, medications, the quantity and distribution of plaque and calculus, smoking and oral hygiene. Other researchers have evaluated secondary factors such as race and/or ethnicity, genetics. epidemiological relations, and patient’s secondary diseases such as diabetes, osteoporosis, and in some cases an entirely compromised immune system .
Periodontists, hygienists, and other health care professionals utilize specific diagnostic tools. Radiographic evaluation of alveolar bone loss, bone density, furcations, root shape, and proximity can help in the periodontal treatment outcomes. During these radiographs, specific scans will help clinicians evaluate their patient more effectively. Such scans include a full-mouth periapical survey, including vertical bite-wings, and in some cases a panographic radiograph that includes selected periapical films. Aside from these diagnostic tools,treatment requires effective communication, education, and listening skills are of particular importance to today’s dental patient. According to Sweeting, Davis, and Cobb (18) ,there are specific words that are highly-recommended to communicate diagnostic findings with patients. For example, the office staff and care givers should demonstrate their communication skills with the correct terminology and diction. In order to be effectively communicate a patient’s periodontal conditions, word choices such as “infection” over “gum inflammation” would help the patient understand that having periodontal disease is an urgent matter. Likewise, using the word “hemorrhage” would indicate the degree of seriousness in caring for periodontal disease. This communication style can complement the periodontal disease diagnosis and prepare a patient for treatment implementation, such as that of non-invasive periodontal treatment.

The aim of non-invasive surgical treatment of periodontitis is considred a Phase I therapy to minimize the bacterial floral present. As Sweeting, Davvis and Cobb (22) stated, this therapy is an “opportune time for the clinician to introduce adjunctive therapies to the patient such as the use of locally delivered antimicrobials.” Similarly, periodontitis patients with special circumstances, like dental implants, should still be wary with the findings of a recent study, that outlines specific phases of treatment to be selected. Therapy of specific types of periodontal disease have shown that periodontitis has little to minimal effects on bone loss in dental implants. In Aloufi et al study (38) , 61 patients randomly selected from patients treated and rehabilitated with dental implants from 1996 to 2001. In the study, participants were separated based on the periodontitis severity: group A with history of the generalized severe chronic form and group B with a history of mild or no chronic. Although the results of diagnostic evaluations such as radiographic bone measurements indicate greater attachment loss around implants placed in patients with severe periodontitis, the results were not statistically significant from the group B, no/mild periodontitis group. In such cases, rehabilitation of patients with periodontitis by dental implant was shown to be successful. Although the study doesn’t label these dental-implant patients as high risk bone-loss groups, this finding’s conclusions advocate close monitoring of patients to prevent development of peri-implantitis and/or reemergence of periodontal disease. Similarily, chronic periodontitis therapy is aimed at repairing the affected area and ultimately allow for regeneration of periodontal structures through future procedures. In Al-Omari, Al-Habashneh and Taani’s findings (847), periodontal structures show little difference between those with aggressive (AgP) and chronic(CP) periodontitis. In this study, age was not used as a limiting factor for diagnosis, as AgP can occur at any age. Using the same diagnostic methods previously mentioned, like radiographic examinations, the subjects of this study were identified as chronic if they had at least a 4-mm attachment loss on more than a quarter of the pocket sites and more than 20% of visible bone loss. Anything short of this quantities would be considered aggressive. Al-Omari, Al-Habashneh and Taani (848) stated, “the common features of the generalized aggressive form of periodontitis were as follows: clinical health of subjects, except for the presence of periodontitis; rapid attachment loss and bone destruction; and familial aggregation.” This study must be taken into consideration as it highlights how AgP and dental caries could be helpful in understanding the etiology and pathogenesis of both caries and periodontal disease.

In a later study, researchers focused on chronic periodontitis treatment. Graziani et al (2009) discused short-term adjunctive effect of systemic neridronate in non-surgical periodontal therapy of advanced generalized chronic periodontitis. This study evaluated the accompanying benefits of complementary neidronate with periodontal treatment. In this study, neidronate was selected for both its safety and therapeutic effects on bone metabolism. Ultimately, the study did not provide new findings for adjunctive non-surgical treatment of chronic periodontitis. Even with the ultimate treatment focus of eliminating subgingival plaque biofilm of dentition, bisphosphonates or BP’s were selected because its ability to to decrease ostoblastic differentiation and inhibit osteoclast recruitment (Graziani et al 420). The total dosage of 12.5 mg/week was within the therapeutic effective range for management of osteoporosis. However, the results illustrate that it was sufficient enough to have an effective outcome on osseous development of the alveolar bone. Nevertheless, neridronate has shown to be generally safe. The only adverse effects of treatment management of this sort include complications such as flu and musculo–skeletal pain occurred and there no incidents of hypocalcaemia reported in this study. Above all, these findings have illustrated the need for future studies to include longer observational periods to establish a long-term complementary treatment medication similar to neridronate.

The overall goal of non-invasive periodontal treatment is to reduce of etiologic factors to reduce or eliminate inflammation, thereby allowing gingival tissues to heal. Supportive treatment of periodontitis should be selected based on this therapeutic outcome. One such supportive therapy includes scaling and root planing.Removal of dental calculus is accomplished by scaling and root planing procedures using various modalities such as hand, sonic, or ultrasonic instruments (American Academy of Periodontology page number). The hope of scaling and root planning is to remove plaque and calculus so that the subgingival bacteria is below capable of initiating clinical inflammation. The objectives of scaling and root planning would allow for inflammation reduction. By reducing the amount of inflammation, the quantitative evaluations of probing depth, clinical attachment levels would thereby decrease. Consequently, root and scaling procedures decrease bacterial flora and ultimately reduces disease progression.

According to Heitz-Mayfield (Citation), microbial treatment monotherapy targets the bacteria that are present in the biofilm structure. Mechanical debridgement is an essential method for removing biofilm bacteria. This debridgement process must coincide with antibiotic treatment as both aim to reduce the amount of bacteria present and lower the amount of inflammation in the periodontal pocket. Together mechanical debridgement and systemic antibiotics must be complementary to be effective factors of periodontitis treatment. Their conclusions illustrate that the antibiotic is most effective when it is initiated within less than a week of mechanical debridgement. Research has shown that monotherapy is not as efficacious: four studies that utilized metronidazole and combined metranidazole and amoxicillin experimental groups concluded that antiobiotic monotherapy has little to minimal effect. Additionally, antibiotics, without subgingival debridgement, will not disrupt the biofilm, and instead will result only in periodontal abscesses. The periodontal abscess is a lesion with extensive periodontal breakdown occurring during a short period of time with localized accumulation of pus. In other cases, isolated mechanical debridement and drainage through the periodontal pocket without any antibiotic treatments usually only effective in the management of the periodontal abscess.

Therapeutic success of an antimicrobial depends on the activity of the antimicrobial agent against the infecting organisms. Periodontitis is a mixed microbial infection making the choice of antibiotic regimen difficult. Certain antibiotics target specific parts of the subgingival biofilm.
The most commonly used antibiotics include tetracyclines, penicillins, like amoxicillin, metronidazole, various macrolides, clindamycin and ciprofloxacin, of which the most common combination is metronidazole and amoxicillin combined. The other antibiotic option of azithromycin is advantageous because of its pharmacologic properties and long half life, which allows patients to take one tablet per day for three straight days, rather than three times a day for seven days for other drug options.


.Drug therapy adds as an accessory non-invasive therapy to scaling and root planning. Previous studies by researchers have questioned the benefits ofl topical antibacterial agents over a period of at least 6 months, which is the standard therapeutic index recommended by ADA . The approved ingredients included in this type of treatment include thymol, methol, eucalpytol and methyl salicylate. Secondary active ingredients include chlorhexidine digluconate and triclosan. Although minimal experimental evidence has supported it’s effects on gingivitis, a complementary topical agent is recommended (American Academy of Periodontology page number) Treatment agents combat the surface and not the deeper plaque. As part of the drug therapy, non-steroidal anti-inflammation drugs and subantimicrobial dose of doxycycline have illustrated some benefits. Recent FDA publishings have shown the use of 20 mg dosage of doxycycline hyclate have demonstrated reducing probing depths, gain in clinical attachments levels and a reduction of disease progression. The only risks of this form of therapy is that there are additional risks such as administered antibiotics include development of resistant bacterial strains,emergence of opportunistic infections, and possible allergic sensitization of patients(Citation). FDA has approved of a tetracycline based fiber along with doxycyclitie in a bioabsorbable polymer gel as a stand-alone therapy for thereduction of probing depths and bleeding upon probing, PD and BOP, respectively. However, this aspect of treatment has limited risks compared to those of using NSAIDS as previously mentioned. The only adverse effects include allergic reaction, possible inability to disrupt biofilms, and failure to remove calculus." Also, direct application drug delivery systems as a form of chemotherapeutic agents provide several benefits; the drug can be delivered to the site of disease activity at a bactericidal concentration and it can help with continued drug delivery and absorption. The ultimate aim of this type of therapy is to halt the progression of periodontal attachment loss by removing etiologic factors.

Additionally, patient compliance is another factor in ultimate therapeutic outcomes of antibiotic administration. Compliance in terms of oral hygiene and maintenance care should also be addressed. It should be recognized that in studies where beneficial results following adjunctive antibiotics were reported, patients had received maintenance care and had good plaque control. Recall that for the other aspects of non-invasive therapy to be effective, personal concern of hygiene is essential. For the dual therapy of debridgement and systemic antibiotics to be effective, patients should utilize oral rinses, hygiene and pain management. The limited side effects of fever and malaise for such dual therapy treatment are far outweighed by the benefits of reducing inflammation by reducing the number of gram-negative anaerobes. The other reported minor and major effects of antibiotic treatment is gastrointestinal problems such as diarrhoea and nausea. However, serious adverse events such as allergic andanaphlyactic reaction and pseudomembranous colitis. In very isolated cases, anaphylactic responses to penicillin have occurred in .01% of the times penicillin was administered (Heitz-Mayfield (Citation).

Supportive treatment modalities must coincide with the patient’s own personal preventative actions. The patient must follow personal plaque control measures. Furthermore, surface, or supragingival irrigation by the patient will allow for bacterial flushing, with the previously mentioned medications can reduce inflammation more effectively than brushing alone. In Radnai et al study "Benefits of Periodontal Therapy when Preterm birth Threatens" has highlighted the importance of personal oral hygiene instructions. The findings highlight significant differences between treatment and control groups relative to each newborn's birthweight and time. The primary advantageous outcomes of periodontal treatment for women were an increase in the mean weight of the newborns and the longer duration of gestation times (APA citation here) This study’s results showed that women had a significant lower chance of adverse pregnancy outcome if they received periodontal therapy before the 35th gestational week. Current results might also provide indirect evidence for the assumption that maternal periodontitis may cause pre-term birth.For this treatment group, oral hygiene instruction and periodontal therapy were provided in the third trimester, while those 42 patients in the control group did not receive any periodontal treatment. I The incidence of pre-term birth and low birthweight in the treatment group was significantly less than in the control group). Periodontal treatment completed before the 35th week appeared to have a beneficial effect on birth weight and time of delivery.

The preventative treatment aspect of periodontitis include detailed and properly communicated patient education process, including plaque control and counseling in management of periodontal and systemic risk factors mentioned previously. The effects of treatment have been supported through research. In Sweeting, Davis, and Cobb’s research (17), the time interval of three months for an indefinite period of time following active therapy, appears to be effective in reducing disease progression, preserving teeth, and controlling the subgingival bacterial burden. These findings illustrate the importance of health care professionals’ commitment to the future outcomes and maintenance of healthy periodontal tissue should include regular re-evaluations after non-surgical treatment. Again, periodontal treatment requires that the patient shows the basic understanding of the etiology of periodontal diseases, treatment options, consequences of nontreatment, and direct benefits of therapy. The inflammatory components of plaque induced gingivitis and chronic periodontitis can be managed effectively for the majority of patients with a plaque control program and non-surgical root debridgement coupled with continued periodontal maintenance procedures and actions such as regenerative therapies. Collectively, health professionals should ensure routine prophylaxis appointments, and ongoing periodontal maintenance to insure no patient is overlooked regarding diagnosis of developing periodontal disease or recurring disease (Citation). .