Sustained Release Locally Applied Antimicrobials
Indications and Contraindications
THE NEXT DDS
Scaling and root planning (SRP) procedures have been used
for years by dental professionals to reduce periodontal pocket depths in adults
with periodontitis. More recently, locally applied antimicrobials (LAAs) have
been approved as an adjunct to SRP for managing such patients. Broad-spectrum
antibiotics, such as minocycline hydrochloride, and antiseptic agents enable
clinicians to create a healthy environment that promotes healing and to target
microorganisms associated with periodontal infection. For the dental student
learner, this article will present the indications and contraindications for
Risk Factors for Periodontal Disease:
- Poor oral hygiene
- Genetic predisposition
- Certain medications
- Complicating systemic
Oral Health Linked to
Approximately 50% of American adults over the age of 30 have some form of
periodontal disease, ranging from mild gingivitis to advanced periodontitis.1
Only a limited number of affected people seek treatment—approximately 3 percent
(Figures 1 and 2).2 With increasing evidence indicating that
periodontal disease is linked to overall health, proper oral hygiene and
infection treatment is critical.
A healthy mouth is one that has a balance of “healthy” and
“unhealthy” bacteria. Poor oral hygiene and other risk factors cause the
periodontopathogenic bacteria, including red complex bacteria, to dominate.
Periodontal disease occurs when biofilms build up at or below the gingiva
(Figure 3). The body’s response to the bacteria and their byproducts is
inflammation. However, these microorganisms are resistant to natural antibodies
and proteins intrinsic in the inflammation and therefore require treatment.
While gingivitis is an infection limited to the gingival
tissues, periodontitis is a chronic and destructive condition that can cause
the decay of bone and tooth loss. Periodontitis occurs when infection spreads
from the gingiva to the ligaments and bone that hold the teeth in place. As the
gingiva pulls away from the teeth due to infection, the teeth become loose and
may eventually fall out.
As periodontitis progresses, the bacteria thrive in the
periodontal pockets caused by the disease. The inflammatory response of the
gingiva may make it easy for bacteria and their byproducts to enter the
bloodstream.3 Chronic periodontal disease has been associated with a
multitude of other diseases and conditions, including heart and lung diseases,
diabetes, rheumatoid arthritis, and premature birth.4,5
The Surgeon General has declared that ‘‘oral health is
essential to the general health and well-being of all Americans.’’ The Surgeon
General’s report on oral health encourages researchers to find new ways to
prevent and treat oral diseases.5 Since the report was issued in
2000, sustained-release LAAs have been approved for treating
SRP Plus LAA and
Pocket Depth Reduction
Scaling and root planing (SRP) procedures have long been the
standard treatment for periodontal disease. For patients with gingivitis (≤ 4mm
pocket depth) or mild periodontitis (4mm - 5mm pocket depth), SRP may be the
only treatment that is needed.
Non-surgical treatments, such as such as hand or ultrasonic
scaling and laser debridement, are not effective in treating moderate-to-severe
cases of periodontitis (pocket depth >5mm). Research indicates that SRP
alone is not effective in eliminating all bacteria.6 In addition,
instrumentation may not reach the furcation region (Figure 4), leaving some
bacteria behind.7 The remaining bacteria can multiply and return to
pre-treatment levels within days.8
Locally applied antimicrobials are antibiotic or antiseptic
agents aimed at reducing bacteria subgingivally (Figures 5 and 6).
Sustained-released LAAs have been proven to reduce pocket depth in adults with
periodontitis when used in conjunction with SRP.9-11
Sustained-release formulas allow the agents to keep working postapplication so
the pocket has time to heal without reinfection (Figures 7 and 8).
There are three sustained-release LLA products currently
approved for the treatment of periodontitis: minocycline HCl (Figures 9-10-11-12), doxycycline hyclate, and chlorhexidine gluconate.
LAAs can be applied in general practice or by a periodontist.
Monocycline HCl is a sustained-release antibiotic in the form of microspheres
that continue working for up to 21 days.12 It is a fine powder
delivered using a blunt-tip cannula directly into the pocket. Monocycline HCl
should not be used in patients with a known sensitivity to minocycline or
tetracyclines. It should not be used in children or pregnant or nursing women.9
Doxycycline hyclate is a sustained-release antibiotic that continues working
for up to 21 days. It is additionally indicated for gain in clinical attachment
and reduction in bleeding on probing. The drug requires mixing prior to
delivery. Syringe A contains a gel-like material into which the antibiotic
(syringe B) is injected. The agent is then delivered directly into the pocket
using a blunt-tip cannula. The gel turns into a waxy consistency when exposed
to water or oral fluids. Doxycycline hyclate should not be used in patients
with a known sensitivity to doxycycline or tetracyclines. It should not be used
in children or pregnant or nursing women.10
Chlorhexidine gluconate is a sustained-release antiseptic chip that continues
working for up to 7 days. Proponents argue that it is favorable because it
cannot cause antibiotic-resistant bacteria. The chip is applied directly to
pockets using forceps. Because of the chip’s size, it can only be used in
pockets 5mm or greater. Chlorhexidine gluconate should not be used in patients
with a known sensitivity to chlorhexidine.11
When to Refer to a
Academy of Periodontology
recommends that adults undergo an annual comprehensive periodontal evaluation.
This includes the evaluation of: teeth, calculus, gingiva, occlusion, bone
structure, and risk factors.13 This comprehensive evaluation should
be conducted by the hygienist and dentist during regularly scheduled cleanings.
Should gingivitis or mild periodontitis be identified, SRP is recommended. This
can be done in general practice or by a periodontist.
Patients should be referred to a specialist for the
treatment of periodontitis in the following cases:
- There is an extreme amount of plaque present.
- There are complications of systemic disease,
such as diabetes.
- Patient is not responding to treatment provided
in the general practice.
- Patient requires conscious sedation for
- Patient requires surgical treatment or dental
- Patient requires perio-systemic management.
More and more patients are presenting with signs of
periodontal disease. Ongoing research indicates that periodontal disease is
linked to other chronic diseases; therefore, periodontal treatment may require
a greater understanding and increased level of expertise by a trained
specialist. Patients who present with moderate or severe levels of periodontal
disease, or patients with more complex cases, are best managed in partnership
between the dentist and periodontist.
PI, Dye B, Wei L, Thornton-Evans G, Genco R. Prevalence of Periodontitis in
Adults in the United States:
2009 and 2010. J Dent Res. 2012;91(10):914-920.
- Dispelling Myths about Gum Disease: The Truth
Behind Healthy Teeth and Gums. American
Accessed March 18, 2014.
Periodontology. Periodontal Disease as a Potential Risk Factor for Systemic
Diseases. J Periodontol. 1998;69:841-850.
- Periodontal Disease Fact Sheet. American Academy of Periodontology. http://www.perio.org/newsroom/periodontal-disease-fact-sheet.
Accessed March 18, 2014.
Department of Health and Human Services. Oral health in America: A
Report of the Surgeon General. DHHS, Rockville,
MD. 2000. Pages 1, 13.
- Goodson JM, Gunsolley JC, Grossi SG, et al.
Minocycline HCL microspheres reduce red-complex bacteria in periodontal disease
therapy. J Periodontol.
- Cobb CM. Non-surgical pocket therapy:
mechanical. Ann Periodontol.
- Socransky SS, Haffajee AD. Biofilms: difficult
therapeutic targets. Periodontol 2000. 2002;28:12-55.
- ARESTIN (minocycline hydrochloride)
Microspheres, 1 mg [Prescribing Information]. Warminster, PA:
OraPharma, Inc.; 2011.
(doxycycline hyclate). http://www.rxlist.com/atridox-drug.htm. Accessed March 18, 2014.
- PerioChip (Chlorhexidine gluconate) 2.5 mg
[Prescribing Information]. Yokneam, Isreal: Dexcel Pharma Technologies Ltd.;
LA, Norderyd OM, Puchalsky CS. Topical application of tetracycline-HCl
in human periodontitis. J Clin Periodontol. 1993;20:88-95.
- Comprehensive Periodontal Evaluation. American Academy of Periodentology. http://www.perio.org/consumer/perio-evaluation.htm.
Accessed March 18, 2014.
Table 1: Locally Administered Antibiotics