This topic include all the drugs that are locally applied in periodontal pocket so that their levels in GCF should be more than blood. Advantages: Can attain higher concentrations at base of pocket Can use drugs that are not suitable for systemic administration Patient compliance is not required Alternative for patients predisposed to adverse drug reactions from systemic administration. Reduced risk for drug resistant microbe development Lower total drug dose INDICATIONS: As an adjunct to mechanical therapy in pockets of 5 mm or greater depth In patients who are systemically compromised & cannot undergo periodontal flap surgery Localized recurrent pockets with supportive periodontal therapy In refractory periodontitis (that is resistant to treatment)

1. Local Drug
Delivery Systems

3. Index
Ideal Requisites
Advantages and Disadvantages
Indications and Contra-indications
Adverse effects
Systemic versus Local drug delivery
Classification: Professionally applied (In Office)
Personally applied (In Home)

4. Index
 Drugs Used Locally in Periodontitis
• 1. Tetracycline Fibers (Actisite)
• 2. Resorbable fibers (Periodontal plus AB)
• 3. Doxycycline Polymer (Atridox) (GEL)
• 4. Microspheres (2% minocycline) (Arestin)
• 5. Ointment (2% minocycline)
• 6. Metronidazole Dental Gel (Elyzol)
• 7. Metrogene
• 8. Chlorhexidine Chip (PerioChip)

5. Index
 Drugs Used Locally in Periodontitis
• 9. Periocol CG
• 10. Chlo-Site
• 11. Ofloxacin Inserts (PT-01)
• 12. Azithromycin 0.5% (bio-absorbable controlled release gel)
• 13. Povidone Iodine
• 14. Alendronate
• 15. Simvastatin
• 16. Growth Factors
 Others
 Conclusion

6. INTRODUCTION
This topic include all the drugs that are locally
applied in periodontal pocket so that their
levels in GCF should be more than blood.

7. Ideal requisites
 Must reach to the base of pocket.
 Must be effective against pathogens
 No effect on host tissues (body)
 Retentive after placement.
 Ease of placement
 Cost effective
 Biodegradable

8. Advantages:
 Can attain higher concentrations at base of pocket
 Can use drugs that are not suitable for systemic administration
 Patient compliance is not required
 Alternative for patients predisposed to adverse drug reactions
from systemic administration.
 Reduced risk for drug resistant microbe development
 Lower total drug dose

9. Disadvantages
Difficulty in placing drug into deeper part of
periodontal pockets and furcation areas
Time consuming
Do not have any effect on bacteria present on
extra pocket oral sites (tongue, oral mucosa)

10. 1. As an adjunct to mechanical therapy in pockets
of 5 mm or greater depth (particularly in
localized periodontitis)
2. In patients who are systemically compromised
& cannot undergo periodontal flap surgery
3. Localized recurrent pockets with supportive
periodontal therapy
4. In refractory periodontitis (that is resistant to
treatment)
Indications

11. Allergic to particular drug used
As a monotherapy (without Scaling and Root Planing)
To pregnant and lactating mothers (only for tetracycline
group of drugs)
In patients with history of immune deficiency (to prevent
the overgrowth of Candida or other resistant organisms)
Contraindications

12. Adverse effects
Allergic reactions
Formation of resistant strains
Occurrence of Candidiasis
Pain on insertion.
Burning sensation on insertion (with
Chlorhexidine)
Abscess formation

13. Systemic vs. Local delivery
Local Drug Delivery Systemic delivery
1. High concentration in the pocket
2. Minimal side effects
3. Patient compliance not required
4. Avoids exposure of drug to non oral
sites
5. Tissues invasive organisms not
always affected
6. More time consuming
1. Less concentration in the pocket
2. More side effects
3. Patient compliance is required
4. Whole body is exposed to the drug
5. Affect tissue invasive organisms
6. Less time consuming

14. Mouth
Wash
Subgingival
Irrigation
Systemic
delivery of
Drug
Local Drug
Delivery
Site delivery
(At base of
pocket)
Less Good Good Good
Concentration
(At base of
pocket)
Good Good Fair Good
Duration of
action
Less Less Fair Good

15. CLASSIFICATION

16. A. Nonsustained subgingival drug delivery
(professional pocket irrigation)
Examples
Conventional oral pulsed irrigator (Waterpik)
Blunt tipped irrigation cannula
1. Professionally applied (In Office)

17. B. Sustained subgingival drug (Controlled release
device)
Examples: Various drug delivery system.
Vehicles used are: Hollow fibers, Acrylic strips,
Monolithic fibers, Collagen, Resorbable Cellulose,
Biodegradable Gel

18. Reservoir without rate controlling
system
Dialysis tube, Gels
Reservoir with rate controlling system
Monolithic devices, Acrylic strips, Ethyl
cellulose strips, Ethyl vinyl acetate
fibers
Controlled release device is of two types

19. A. Nonsustained subgingival drug delivery
(Home oral irrigation with Mouthwashes)
B. Sustained subgingival drug (None
developed)
2. Personally applied (In Home)

20. Various drug
delivery
system

21. Broad spectrum antibiotic - activity against both
gram positive and gram negative organisms
Tetracycline, doxycycline and minocycline - with
similar spectrum of activity, hence resistance to one
indicates resistance to all three.
Bacteriostatic agents but has bactericidal effects
in high concentrations.
Acts by inhibiting protein synthesis
TETRACYCLINES

22. Functions of tetracyclines:
 Antibacterial action
 Inhibits MMPs (Matrix Metalloproteinase)
 Demineralizes cementum and dentin, when
applied topically thereby enhancing
attachment of fibroblasts to the tooth
surface

23. • Non-resorbable cylindrical drug delivery
devices made of biologically inert,
ethylene/vinyl acetate co-polymer fiber
loaded with 12.7mg tetracycline per 9
inches.
• 23 cm in length and 0.5 mm in diameter
• First local delivery drug used in US
1. Tetracycline Fibers
(Actisite)

24. Flexible, and can be folded on itself to nearly fill the
pocket and able to produce and maintain a
concentration of 1, 300µg/ml for a period of 7 days
whereas only 32-64µg/ml is required for inhibition of
pathogens from periodontal pocket
After systemic administration of tetracycline (4 times
a day for 10 days), produce GCF concentration of 4-
8µg/ml

25. Monolithic fibers: a mixture of 25% tetracycline HCL
and 75% ethylene vinyl acetate was heated to 214
degree C; extruded as 0.5 mm diameter fiber; provide
controlled release system.
 Not available and used now

26. 2. Resorbable fibers
(Periodontal plus AB):
•Tetracycline is incorporated
into cross linked collagen
matrix.
•Deliver tetracycline for upto
10 days after insertion
•Drug levels ranged from 17
to 180µg/ml.

27. Procedure
Short lengths of fiber, 2-3 inches are taken in cotton
forceps, placed at opening of pocket, folded on itself until
all pockets are nearly filled.
Interproximal pockets should be packed from both buccal
and lingual sides
Periodontal pack is given for a week
Fiber removal (in case of non-resorbable fibers) can be
done with curette.

28. Post-operative instructions:
Not to brush or floss treated areas until fibers are removed/
for one week
To rinse with chlorhexidine mouth rinse for two weeks
Advised to start normal original oral hygiene procedure
after 1 week or after fiber removal (in case of non-
resorbable fibers)
To come for recall visits at 4-6 weeks.

29. 3. Doxycycline Polymer
(Atridox) (GEL)
Biodegradable
Formulation contains 10% by weight
doxycycline, 33% by weight Poly (DL-
lactide) and 57% by weight N-methyl-2-
pyrrolidone (2 syringe mixing system)
It is liquid biodegradable system that
hardens when placed in periodontal
pocket.
DOXYCYCLINE

30. Doxycycline Polymer
(Atridox) (GEL)
Syringe A contains Poly (DL-lactide)
and N-methyl-2-pyrrolidone (Delivery
system)
Syringe B contains doxycycline hyclate
Two syringes are mixed

31. Procedure
10% doxycycline hyclate is contained within syringe that
has blunt ended 23 gauge cannula
Tip of cannula is introduced to depth of pocket and drug is
expressed out and it hardens in contact with moisture
It is packed into pocket using underside of moistened
curette or other blunt-ended instrument immediately after
placement
Polymer slightly protrudes from pocket orifice
Periodontal pack given for 1 week

32. Minocycline
Three modes of local application are available:
Film: ethyl-cellulose film containing 30% of minocycline
Microspheres (2% minocycline) (Arestin).
Minocycline Ointment (2% minocycline) (Periocline;
Dentomycin)

33. 4. Microspheres (2% minocycline) (Arestin)
o Minocycline microencapsulated in bioresorbable
microspheres in a gel carrier; administered by means of
disposable plastic syringe.
o FDAApproved
o Resorption time of 21days

34. 5. Ointment (2% minocycline): light yellow colored
ointment, supplied in disposable polypropylene applicator
Available as ‘Periocline’ and ‘Dentomycin’

35.  5-nitroimidazole compound specifically targets
anaerobic microbes
 Upon entry into an organism, metronidazole is
reduced at 5-nitro position by electron transport
proteins, producing free radicals. These react with
bacterial DNA causing cell death.
 Thus primarily bactericidal
METRONIDAZOLE

36. 6. Metronidazole Dental Gel
(Elyzol)
Bio-absorbable delivery device
Containing 25% metronidazole benzoate in matrix
consisting of mixture of glyceryl mono-oleate and
sesame oil.
Gel is sub-gingivally placed with syringe and blunt
cannula.
Sustained drug delivery

37. 7. Metrogene
 New combination of two known
substances; Bovine collagen
(type I) sponges into which 5
percent metronidazole is
incorporated
In GCF, the collagen rapidly
forms a resorbable gel
releasing the drug

38. Topical antiseptic belonging to family of Bis-biguanides.
Mainly active against gram positive, gram negative organisms,
yeasts, fungi
Bacteriostatic at lower and bactericidal at higher
concentrations.
CHLORHEXIDINE

39. 8. Chlorhexidine Chip (PerioChip)
• Bio-absorbable device comprising 34% chlorhexidine in
biodegradable cross linked gelatin matrix.
• Each chip is 5 mm long, 4 mm wide, and .35 mm thick
pliable strip loaded with 2.5 mg of chlorhexidine.
• Releases drug and maintain concentration in GCF greater
than 100µg/ml for at minimum of 7 days.

40. Technique of placement :
 After scaling and root planing, chip is grasped in
cotton forceps and gently inserted into pocket.
 Dry the area before placing the chip. As burning
sensation may be reported after chip placement,
placement of multiple chips around a single tooth
may result in discomfort.
 Chip degrades in 7-10 days and requires no retentive
system

41. 9. Periocol CG
2.5 mg chlorhexidine (20% chlorhexidine solution)
in collagen membrane.
Size of chip- 4 x 5 mm and thickness is 0.25 - 0.32
mm
Collagen is a natural protein, chemotactic for
fibroblasts, enhances fibroblast attachment via its
scaffold like fibrillar structure. It also stimulates
platelet degranulation, thereby accelerating fibers
and clot attachment.
Resorb after 30 days; however coronal edge
degrades within 10 days

42. 10. Chlo-Site
Contains 1.5% chlorhexidine of xanthan gel ( saccharide
polymer, three-dimensional mesh)
Vanish from pocket within l0-30 days of injection and
effective concentration of chlorhexidine against
microorganisms is established for at least 15 days in
region.
Both chlorhexidine and gel matrix are muco-adhesive so
that they stick inside pockets and are not easily washed out
by gingival fluid or saliva.
Advantages: degrades spontaneously at site of application,
well tolerated and efficient in treatment of periodontal
pockets & periimplantitis

43. • Belongs to quinolone family
• Bactericidal- inhibit DNA replication by acting on
enzyme DNA gyrase.
• Bactericidal
OFLOXACIN

44. 11. Ofloxacin Inserts (PT-01)
• Soluble insert, with fast and sustained release containing
10% W/v ofloxacin, and showed a constant drug level of above
2 mg/ml, which could be sustained for up to 7 days.
• Controlled release system exhibited biphasic pattern with a
rapid early release phase, peaking at approximately 12µg/ml
and stabilizing at approximately 2µg/ml from day 3 to 7 following
insertion.

45. Macrolides, broad spectrum activity
Predominantly bacteriostatic drug & interfere with
bacterial protein synthesis by binding to 50s
ribosomal unit
12. Azithromycin 0.5% ( bio-absorbable controlled
release gel)- is used as an adjunct to non-surgical
mechanical therapy in treatment of chronic
periodontitis
AZITHROMYCIN

46. 13. Povidone Iodine
• Kills both gram positive and negative bacteria, viruses,
fungi, spores, protozoa and amoebic cysts.
• Microbicidal activity of povidone iodine is retained in
presence of blood, pus and serum.
• Used as subgingival irrigation.

47. The active moiety is iodine, oxidises
pathogen nucleotides and fatty/amino
acids and thus inactivates proteins and
DNA/RNA.
Mechanism of action

48. 14. ALENDRONATE
 Novel bisphosphonate & very potent inhibitor of
bone resorption.
 Net effect of alendronate on bone formation-
inhibition of osteoclasts, apoptosis of osteoclasts,
increase osteoblastic differentiation.
 Used along with graft material in bony defects

49. 15. SIMVASTATIN
 Statins like Simvastatin, Lovastatin, and Pravastatin lower
cholesterol & provide important and effective approach for
treatment of hyperlipidemia and arteriosclerosis.
 Statins modulate bone formation by increasing expression of
bone morphogenetic protein-2, angiogenesis.
 Assists in bone regeneration as well as anti-inflammatory
effect when delivered or applied locally.

50.  Platelet-derived growth factor (PDGF), Vascular endothelial growth
factor (VEGF)
 Involved in mitogenesis, angiogenesis, bone regeneration and enhance
periodontal wound healing
 Used along with bone grafts in bony defects
16. Local Delivery Of Growth Factors

51.  Curcumin
Herbal Combinations
Neem Extract
Spirulina
Chitosan PVA based local delivery system
Other agents used as LDD

52. CONCLUSION
• In conjunction with scaling and root
planing, adjunctive use of local drug
delivery devices may enhance results in
sites which do not respond to
conventional therapy.