Periodontal Medicaments

Periodontal diseases often require adjunctive therapies to traditional mechanical treatments such as scaling and root planing. Various medicaments have been developed to enhance the healing process and control infection in periodontal tissues. This lecture will discuss several periodontal medicaments, their compositions, and their clinical applications.

1. Elyzol

• Composition:
  • Elyzol is an oil-based gel containing 25% metronidazole. It is formulated with glyceryl mono-oleate and sesame oil.
• Clinical Use:
  • Elyzol has been found to be equivalent to scaling and root planing in terms of effectiveness for treating periodontal disease.
  • However, no adjunctive effects beyond those achieved with mechanical debridement have been demonstrated.

2. Actisite

• Composition:

  • Actisite consists of tetracycline-containing fibers.
  • Each fiber has a diameter of 0.5 mm and contains 12.7 mg of tetracycline per 9 inches of fiber.

• Clinical Use:

  • The fibers are placed directly into periodontal pockets, where they release tetracycline over time, helping to reduce bacterial load and promote healing.

3. Arestin

• Composition:

  • Arestin contains minocycline, which is delivered as a biodegradable powder in a syringe.

• Clinical Use:

  • Arestin is indicated for the treatment of periodontal disease and is applied directly into periodontal pockets, where it provides localized antibiotic therapy.

4. Atridox

• Composition:

  • Atridox contains 10% doxycycline in a syringeable gel system that is biodegradable.

• Clinical Use:

  • The gel is injected into periodontal pockets, where it solidifies and releases doxycycline over time, aiding in the management of periodontal disease.

5. Dentamycin and Periocline

• Composition:

  • Both Dentamycin and Periocline contain 2% minocycline hydrochloride.

• Clinical Use:

  • These products are used similarly to other local delivery systems, providing localized antibiotic therapy to reduce bacterial infection in periodontal pockets.

6. Periochip

• Composition:

  • Periochip is a biodegradable chip that contains chlorhexidine.

• Clinical Use:

  • The chip is placed in the gingival crevice, where it releases chlorhexidine over time, providing antimicrobial action and helping to control periodontal disease.

Alveolar Process

The alveolar process is a critical component of the dental anatomy, providing support for the teeth and playing a vital role in periodontal health. Understanding its structure and composition is essential for dental professionals in diagnosing and treating various dental conditions.

Components of the Alveolar Process

1. External Plate of Cortical Bone:

   • Description: The outer layer of the alveolar process is composed of cortical bone, which is dense and forms a protective outer shell.
   • Composition:
     • Formed by Haversian bone, which consists of organized structures called osteons.
     • Compacted bone lamellae contribute to the strength and stability of the alveolar process.

2. Alveolar Bone Proper:

   • Description: The inner socket wall of the alveolar process is known as the alveolar bone proper.
   • Radiographic Appearance:
     • It is seen as the lamina dura on radiographs, appearing as a radiopaque line surrounding the tooth roots.
   • Histological Features:
     • Contains a series of openings known as the cribriform plate.
     • These openings allow neurovascular bundles to connect the periodontal ligament with the central component of the alveolar bone, which is the cancellous bone.

3. Cancellous Bone:

   • Description: Located between the external cortical bone and the alveolar bone proper, cancellous bone consists of trabecular structures.
   • Function:
     • Acts as supporting alveolar bone, providing strength and flexibility to the alveolar process.
   • Interdental Septum:
     • The interdental septum consists of cancellous supporting bone enclosed within a compact border, providing stability between adjacent teeth.

Structural Characteristics

• Facial and Lingual Portions:
  • Most of the facial and lingual portions of the tooth socket are formed by compact bone alone, providing robust support for the teeth.
• Cancellous Bone Distribution:
  • Cancellous bone surrounds the lamina dura in specific areas:
    • Apical Areas: The region at the tip of the tooth root.
    • Apicolingual Areas: The area where the root meets the lingual surface.
    • Interradicular Areas: The space between the roots of multi-rooted teeth.

Some important points about the periodontal pocket :
·Soft tissue of pocket wall shows both proliferative & degenerative changes
·Most severe degenerative changes are seen on the lateral wall of pocket
·Plasma cells are the predominant infiltrate (80%). Others include lymphocytes & a scattering of PMNs
·Height of junctional epithelium shortened to only 50-100µm
·Severity of degenerative changes is not linked to pocket depth
·Junctional epithelium starts to lose attachment to tooth when PMN infiltration in junctional epithelium increases above 60%.

Periodontal Fibers

Periodontal fibers play a crucial role in maintaining the integrity of the periodontal ligament and supporting the teeth within the alveolar bone. Understanding the different groups of periodontal fibers is essential for comprehending their functions in periodontal health and disease.

1. Gingivodental Group

• Location:
  • Present on the facial, lingual, and interproximal surfaces of the teeth.
• Attachment:
  • These fibers are embedded in the cementum just beneath the epithelium at the base of the gingival sulcus.
• Function:
  • They help support the gingiva and maintain the position of the gingival margin.

2. Circular Group

• Location:
  • These fibers course through the connective tissue of the marginal and interdental gingiva.
• Attachment:
  • They encircle the tooth in a ring-like fashion.
• Function:
  • The circular fibers help maintain the contour of the gingiva and provide support to the marginal gingiva.

3. Transseptal Group

• Location:
  • Located interproximally, these fibers extend between the cementum of adjacent teeth.
• Attachment:
  • They lie in the area between the epithelium at the base of the gingival sulcus and the crest of the interdental bone.
• Function:
  • The transseptal fibers are primarily responsible for the post-retention relapse of orthodontically positioned teeth.
  • They are sometimes classified as principal fibers of the periodontal ligament.
  • Collectively, they form the interdental ligament of the arch, providing stability to the interproximal areas.

4. Semicircular Fibers

• Location:
  • These fibers attach to the proximal surface of a tooth immediately below the cementoenamel junction (CEJ).
• Attachment:
  • They go around the facial or lingual marginal gingiva of the tooth and attach to the other proximal surface of the same tooth.
• Function:
  • Semicircular fibers help maintain the position of the tooth and support the gingival tissue around it.

5. Transgingival Fibers

• Location:
  • These fibers attach to the proximal surface of one tooth and traverse the interdental space diagonally to attach to the proximal surface of the adjacent tooth.
• Function:
  • Transgingival fibers provide support across the interdental space, helping to maintain the position of adjacent teeth and the integrity of the gingival tissue.

Periodontal Diseases Associated with Neutrophil Disorders

1. Acute Necrotizing Ulcerative Gingivitis (ANUG)

   • Description: A severe form of gingivitis characterized by necrosis of the interdental papillae, pain, and foul odor.
   • Association: Neutrophil dysfunction can exacerbate the severity of ANUG, leading to rapid tissue destruction.

2. Localized Juvenile Periodontitis

   • Description: A form of periodontitis that typically affects adolescents and is characterized by localized bone loss around the permanent teeth.
   • Association: Impaired neutrophil function contributes to the pathogenesis of this condition.

3. Prepubertal Periodontitis

   • Description: A rare form of periodontitis that occurs in children before puberty, leading to rapid attachment loss and bone destruction.
   • Association: Neutrophil disorders can play a significant role in the development and progression of this disease.

4. Rapidly Progressive Periodontitis

   • Description: A form of periodontitis characterized by rapid attachment loss and bone destruction, often occurring in young adults.
   • Association: Neutrophil dysfunction may contribute to the aggressive nature of this disease.

5. Refractory Periodontitis

   • Description: A form of periodontitis that does not respond to conventional treatment and continues to progress despite therapy.
   • Association: Neutrophil disorders may be implicated in the persistent nature of this condition.

Transforming Growth Factor-Beta (TGF-β)

Transforming Growth Factor-Beta (TGF-β) is a multifunctional cytokine that plays a critical role in various biological processes, including development, tissue repair, immune regulation, and inflammation. Understanding its functions and mechanisms is essential for appreciating its significance in health and disease.

Overview of TGF-β

1. Half-Life:

   • Active TGF-β has a very short half-life of approximately 2 minutes. This rapid turnover is crucial for its role in dynamic biological processes.

2. Functions:

   • TGF-β is involved in several key physiological and pathological processes:
     • Development: Plays a vital role in embryonic development and organogenesis.
     • Tissue Repair: Promotes wound healing and tissue regeneration by stimulating the proliferation and differentiation of various cell types.
     • Immune Defense: Modulates immune responses, influencing the activity of immune cells.
     • Inflammation: Regulates inflammatory processes, contributing to both pro-inflammatory and anti-inflammatory responses.
     • Tumorigenesis: Involved in cancer progression, where it can have both tumor-suppressive and tumor-promoting effects depending on the context.

3. Cellular Effects:

   • Stimulates:
     • Osteoblasts: Promotes the differentiation and activity of osteoblasts, which are responsible for bone formation.
     • Fibroblasts: Enhances the proliferation and activity of fibroblasts, contributing to extracellular matrix production and tissue repair.
   • Inhibits:
     • Osteoclasts: Suppresses the activity of osteoclasts, which are responsible for bone resorption.
     • Epithelial Cells: Inhibits the proliferation of epithelial cells, affecting tissue homeostasis.
     • Most Immune Cells: Generally inhibits the activation and proliferation of various immune cells, contributing to its immunosuppressive effects.

4. Production and Activation:

   • TGF-β is produced as an inactive propeptide (latent form) and requires activation to become biologically active.
   • Activation Conditions: The activation of TGF-β typically requires acidic conditions, which can occur in various physiological and pathological contexts, such as during inflammation or tissue injury.

Clinical Implications

1. Wound Healing:

   • TGF-β is crucial for effective wound healing and tissue repair, making it a target for therapeutic interventions in regenerative medicine.

2. Bone Health:

   • Its role in stimulating osteoblasts makes TGF-β important in bone health and diseases such as osteoporosis.

3. Cancer:

   • The dual role of TGF-β in tumorigenesis highlights its complexity; it can act as a tumor suppressor in early stages but may promote tumor progression in later stages.

4. Autoimmune Diseases:

   • Due to its immunosuppressive properties, TGF-β is being studied for its potential in treating autoimmune diseases and in transplant medicine to prevent rejection.