title: Subgingival delivery of oral debriding agents: a proof of concept.
abstract: OBJECTIVE
  This study is a proof of concept to determine the efficacy of a custom-fabricated tray in placing antimicrobial and debriding agents in the periodontal pockets of persons with active gingival infections. Localized subgingival delivery of antimicrobial and antibiotic agents is routinely employed as adjunctive therapy for the treatment and management ofperiopathogens associated with periodontal disease. Because these delivery techniques often face time constraints and impose temporary restrictions on patient brushing and flossing, a custom-formed prescription dental tray can be used to deliver and maintain medications in periodontal pockets between office visits and without brushing or flossing restrictions. The ability of this tray to maintain sufficient concentrations of medication in the periodontal pockets to have a therapeutic effect is evaluated here with theoretical modeling and practical application.
  
  
  METHODS
  Hydrogen peroxide is an oral debriding agent and oral wound cleanser with antimicrobial properties. The debriding effect of 1.7% hydrogen peroxide gel was tested in vitro on Streptococcus mutans biofilm using glass carriers for collection. Diffusion modeling tested the potential of the customized tray to place hydrogen peroxide gel into the sulcus in the presence of crevicular fluid flow. Changes in periodontal microflora with scanning electron microscopy analysis of in vivo paper point site sampling were analyzed before and after a thin ribbon of 1.7% hydrogen peroxide gel (approximately 0.7 gm) and a subtherapeutic dose (three drops) of Vibramycin (50 mg/5 ml) were placed via Perio Trays into periodontal pockets, ranging from 4-8 mm at daily prescribed intervals for two to five weeks.
  
  
  RESULTS
  In vitro results indicate that 1.7% hydrogen peroxide gel breaks down the exopolysaccharide slime and cell walls ofS. mutans, and begins to debride the cells from glass carriers within 10 minutes. Diffusion modeling indicates that hydrogen peroxide can penetrate into the deeper pockets (9 mm), but also its concentration in these deep pockets will increase over wearing time in the absence of degradation by peroxidases and catalase. Site sampling data confirm diffusion modeling results, with evidence that medication delivered with the prescription tray reduced subgingival bacterial loads and enhanced healing of corresponding oral tissues.
  
  
  CONCLUSIONS
  The prescription Perio Tray effectively placed medication in the gingival sulcus. Mathematical modeling indicated Perio Tray placement of hydrogen peroxide gel in periodontal pockets with depths up to 9 mm over 15 minutes treatment time was theoretically possible. Pathology reports reveal reductions in subgingival bacterial loads and improvements in pretreatment pocket depths of up to 8 mm after 1.7% hydrogen peroxide and Vibramycin Syrup were prescribed for use with the Perio Tray. The in vitro analysis indicating that hydrogen peroxide is the active and effective oral debriding agent needs to be confirmed with additional studies.
authors.affiliation: Perio Protect LLC, St. Louis, MO, USA.
authors.forename: Tanya
authors.initials: T
authors.lastname: Dunlap
authors.forename: Duane C
authors.initials: DC
authors.lastname: Keller
authors.forename: Milton V
authors.initials: MV
authors.lastname: Marshall
authors.forename: J William
authors.initials: JW
authors.lastname: Costerton
authors.forename: Christoph
authors.initials: C
authors.lastname: Schaudinn
authors.forename: Betty
authors.initials: B
authors.lastname: Sindelar
authors.forename: John R
authors.initials: JR
authors.lastname: Cotton
mesh_terms: D000328:Adult; D000368:Aged; D000900:Anti-Bacterial Agents / Q000008:administration & dosage*; D000890:Anti-Infective Agents / Q000008:administration & dosage*; D001419:Bacteria / Q000145:classification / Q000187:drug effects; D058491:Bacterial Load / Q000187:drug effects; D018441:Biofilms / Q000187:drug effects; D002473:Cell Wall / Q000187:drug effects; D004058:Diffusion; D004318:Doxycycline / Q000008:administration & dosage; D016503:Drug Delivery Systems; D005260:Female; D005883:Gingival Crevicular Fluid / Q000187:drug effects / Q000382:microbiology; D005884:Gingival Hemorrhage / Q000188:drug therapy / Q000382:microbiology; D006801:Humans; D006861:Hydrogen Peroxide / Q000008:administration & dosage; D008297:Male; D008855:Microscopy, Electron, Scanning; D008875:Middle Aged; D008954:Models, Biological; D010514:Periodontal Pocket / Q000188:drug therapy* / Q000382:microbiology / Q000473:pathology; D010517:Periodontics / Q000295:instrumentation*; D011135:Polysaccharides, Bacterial / Q000187:drug effects; D013295:Streptococcus mutans / Q000187:drug effects; D013997:Time Factors
chemical_list: D000900:Anti-Bacterial Agents; D000890:Anti-Infective Agents; D011135:Polysaccharides, Bacterial; D006861:Hydrogen Peroxide; D004318:Doxycycline