EXAM I Chemotherapy and Plaque Control Flashcards
(169 cards)
1
Q
what is the goal of oral hygiene?
A
to provide an environment that encourages normal flora (health) and prevent growth of pathogenic flora
2
Q
in what 3 ways can oral hygiene be achieved?
A
- mechanical
- chemical
- combination of means
3
Q
describe mechanical plaque control
A
- primary method to prevent dental disease and maintain oral health
- patient education and OHI with proper aids is critical
4
Q
what are 6 reasons why oral hygiene can’t always be controlled by mechanical means alone
A
- motivation
- lack of understanding
- impaired manual dexterity
- systemically compromised
- inaccessable (deep pockets, furcations)
- tooth brushing (reaches 1-2mm)
- flossing (reaches 2-3mm)
- recent oral/periodontal surgery
5
Q
what are the 2 clinical benefits of chemotherapeutic agents?
A
- antimicrobial actions
- ability to increase the host’s resistance
6
Q
what are 4 chemotherapeutics used in periodontal treatment management?
A
- systemic antibiotics
- drugs that modulate host response
- periostat, NSAIDS
- topical antimicrobial agents
- mouth rinses, dentrifices
- drug deliver systems
- “controlled”
7
Q
name 5 desirable characteristics of local chemotherapeutics
A
- substantivity (sticks to the surface)
- low toxicity
- high potency
- good permeability
- intrinsic efficacy
8
Q
describe first generation chemotherapeutics
A
- agents that have antimicrobial activity
- phenolic, H2O2
9
Q
describe second generation chemotherapeutics
A
- agents that have antimicrobial activity and proven substantivity
- CHX, local delivery
10
Q
describe third generation chemotherapeutics
A
- agents that target specific bacteria or bacterial products that are essential to disease development (none available today) and have proven substantivity
11
Q
what are the 4 antimicrobial activities of chemotherapy on plaque?
A
- bacteriocidal
- bacteriostatic
- substantivity
- inhibitory dosage
12
Q
what is the ADA seal for chemotherapeutic agents for the control of gingivitis?
A
to make a plaque control, the benefit must demonstrate significant effects against gingivitis
13
Q
what is the efficacy data of chemotherapeutic agents for the control of gingivitis?
A
- statistically significant for both the reduction of gingivitis and inhibition of plaque
14
Q
safety data of chemotherapeutic agents for the control of gingivitis:
soft/hard tissues
A
no deleterious effects
15
Q
safety data of chemotherapeutic agents for the control of gingivitis:
oral flora (microbiology)
A
no development of opportunistic or pathogenic organisms
16
Q
safety data of chemotherapeutic agents for the control of gingivitis:
toxicology
A
- possible toxic/adverse effects
- document any mutagenic/carcinogenic effects
17
Q
what are some common topical anti-microbials?
A
- chlorhexidine
- essential oils
- oxygenating agents
- povidine iodine
- quaternary ammonium compounds
- sanguinarine
- sodium benzoate, sodium lauryl sulfate, and sodium hypochlorite
- stannous fluoride (SnF)
- triclosan
- zinc chloride
18
Q
describe localized chemotherapeutics
A
- topical antimicrobials
- mouthrinses, gels, dentrifices (toothpaste)
- site specific local drug delivery by professionals
19
Q
what are 4 patient options for localized chemotherapeutics?
A
- over the counter rinses
- Rx rinses
- home irrigation
- dentrifice
site specific local drug delivery by professionals
20
Q
describe chlorhexidine
A
- “CHX”
- the “gold standard”
- cationic bisbiguanide
- 0.12% chlorhexidine digluconate (bisbiguanide)
- 11.6% alcohol
21
Q
what is the pH of CHX?
A
5.5
22
Q
T or F
CHX has the ADA seal and is FDA approved
A
true
23
Q
is CHX effective?
A
yes, it is a highly effective agent
24
Q
what is the mechanism of action of CHX?
A
- ruptures cell membranes
- good substantivity
- broad spectrum
- effective against gram +, gram -, and yeast
25
describe the substantivity of CHX
* binds to soft tissues
* 30% retained after 8-12 hours
* detectable in saliva 8-12 hours later
26
what are 6 side effects of CHX?
* staining
* increased supragingival calculus
* altered taste sensation
* reversible desquamation
* transient swelling of salivary glands
* rare hypersensitivity
27
what is the available concentration of CHX available in the US? what is it outside of the US?
* in the US:
* 0.12% with 11.6% alcohol (and H2O)
* outside the US:
* 0.2%
* no significant different in antimicrobial or clinical effects
28
how much does CHX reduce pland and gingivitis?
* reduces plaque by 50-55%
* reduces gingivitis by 45%
29
what are the patient instructions for the administration of CHX?
* 2x daily
* 30 second rinsing with 1/2 oz (15ml)
* allow 30 minutes between rinsing with CHX and brushing teeth
30
how is CHX affected by sodium lauryl sulfate and fluoride ion?
reduces the effectiveness of the CHD
31
what is the effect of pre-rinsing with CHD?
* ehanced wound healing for extractions, SRPs, and periodontal surgeries
* 30-60 second pre-rinse can reduce bacterial load by \>90-95%
* significantly decreases aerosol contamination/bacteremia
32
what are 3 main uses for CHX rinses?
* gingivitis rampant caries
* candida infections
* dentures
* immunocompromised
* post-op (oral/perio surgeries)
* tongue piercing after-care
33
what are 4 examples of phenolic related essential oils?
* thymol
* menthol
* eucalyptol
* methyl salicylate
34
describe phenolic related essential oils
* oldest product (1865 - Lister)
* ADA approved
* listerine (original product) and over 60 generics
35
when was listerine (essential oil) developed, marketed, and when were new formulations made available?
* developed in 1879
* marketed in 1881
* new formulations in 1992
36
what is the main example of essential oils?
listerine
37
what is the method of action for essential oils like listerine?
* cell wall disruption and inhibition of bacterial enzymes
* contains:
* thymol
* eukalyptol
* menthol
* methyl salicylate
* can "extract" LPS
* anti-inflammatory properties
38
what is the pH of listerine?
4.2
39
what is the alcohol content of listerine?
ranges from 22-27% depending on the brand
40
what are the patient instructions for listerine use?
30 second rinses with 2/3 oz AM and PM
41
how much do phenolic essential oils reduce plaque and gingivitis?
* 20-34% reduction in plaque
* 28-34% reduction in gingivitis
42
what is the effect of phenolic essential oils on candida?
it has an anti-candida effect
43
what are the benefits of phenolic essential oils?
* decreases plaque and increases wound healing 7 days (oral surgery)
* when used as a pre-rinse for SRP:
* \>90% reduction of bacteria in aerosols
44
what is the benefit of thymol in essential oils?
principal antibacterial component
45
do essential oils have high or low substantivity?
* low substantivity (first generation)
* effectiveness related to duration of contact
46
what are 3 side effects of essential oils?
* burning
* bitter taste
* possible staining
47
can listerine be used as a replacement for flossing?
* no, although ads claimed that listerine is as effective as flossing in reducing interdental plaque and gingivitis
* recommendation is to use listerine as an adjunct to brushing and flossing
48
what is the requirement for ADA approval for a product to claim a reduction in gingivitis?
* requires that the product be able to demonstrate a 20% reduction of gingivitis
* only chlorhexidine and listerine can make this claim
49
T or F
there are many studies that address the use topical antimicrobials, like chlorhexidine and listerine, for periodontitis
false
there are no studies
50
what are 5 examples of quaternary ammonium compound products?
* viadent
* scope
* cepacol
* clear choice
* crest pro-health rinse
51
what are the available concentrations of quaternary ammonium compounds (cetylpyridinium)?
* 0.045-0.07% cetylpyridinium (CPC)
* range 0-18% alcohol
52
what is the pH of CPC?
5.5-7.0
53
what is the effect of dentrifice abrasives and flavoring agents on CPC?
alters activity
54
T or F
there is no waiting requirement between rinsing with CPC and brushing
false
at least 30 minutes between rinsing and brushing
55
what is the method of action of quaternary ammonium compounds?
* rupture cell walls
* cationic surface active
* they bind but release rapidly; limits substantivity
56
what is the effect of quaternary ammonium compounds on plaque and gingivitis?
* 14% reduction in plaque
* 24% reduction in gingivitis
57
describe in detail the mechanism of action of CPC
* initial attachment is strong (cation)
* released from binding site more rapidly than CHX
* increases cell wall permeability
* decreases cell metabolism
* decreases ability to attach to the tooth
58
what is the difference in ethanol content between the original listerine developed in 1879 vs. newer products?
* 26.9% (original)
* 21.6% (newer products)
59
does CPC have the ADA seal?
no
60
at what general rate is CPC cleared from the mouth?
rapidly
61
according to published research on CPC, was there a difference between placebo and CPC groups?
no
62
describe the gingival inflammation benefit of crest pro-health vs placebo
* the use of crest pro-health reduced gingival inflammation compared to the placebo
* reduction of 13% at 3mo, and 15% at 6mo
63
describe the gingival bleeding benefit of crest pro-health vs placebo
* reduction in bleeding with use of crest pro-health compared to placebo
* reducted by 23% at 3mo, and 33% at 6mo
64
describe the plaque benefit of crest pro-health vs placebo
* crest pro-health resulted in a reduction in plaque compared to the placebo
* reduced plaque by 20% at 3mo, and 16% at 6mo
65
what types of patients should you consider the use of alcohol-free rinse for?
* children (6+ years), including orthodontic patients
* patients with dry mouth
* diabetics
* alcoholics
* patients with sensitive soft tissue
* patients undergoing chemotherapy
* patients of certain religious faiths
66
what is sanguinarine?
* herbal alkaloid extract from blood root
* studied in mouthwash and dentrifices
67
discuss studies of sanguinarine used in mouthwash and dentrifices
* claims most effective when agents are used together
* claimed to reduce plaque 17-42% and gingivitis 18-75%
68
is sanguinarine available in the US? why or why not?
* no
* supporting research data had mixed and questionable results
* data supported increased leukoplakia in patients and increased risk for cancer
69
what are some oxygenating products used for the control of plaque and gingivitis?
* oxyfresh, hydrogen peroxide, peroxyl
70
what is the mechanism of action of oxygenating products?
* inhibits anaerobic bacteria
* may have short-term anti-inflammatory properties
71
describe safety concerns of oxygenating products
* black, hairy tongue
* tissue injury
* co-carcinogen
* delayed wound healing
72
does research support the use of oxygenating products for the control of plaque and gingivitis?
no
73
what is plax?
* pre-brushing rinse
* 2% sodium benzoate
* 0.25% sodium lauryl sulfate
* sodium salicylate 0.2%
* 8.7% alcohol
74
describe plax research
* disparity in the research
* no ADA seal
75
describe povidone iodine (betadyne) as a use for the control of plaque and gingivitis
* polyvinyl-pyrrolidone and iodine
* pre-procedural rinse (5%)
* rinse for 30sec
* bacteria will not respond for 90min
76
povidone iodine has a broad spectrum for what 3 things?
bacteria, fungi, and viruses
77
povidone iodine used in combination with ___ results in a significant reduction in \_\_\_
* H2O2
* bleeding
* \*studies also show good results when used in combination with SRP
78
what are the side effects of povidone iodine?
* development of toxicity
* allergy
* avoid in pregnant women and thyroid reduction
* stian
79
describe the use of sodium hypochlorite for the control of plaque and gingivitis
* one of the first antimicrobials used as a locally delivered treatment for periodontitis (antiform irrigation)
* low cost and easy to use
80
sodium hypochlorite has a broad spectrum for what 3 things?
bacteria, fungi, and viruses
81
sodium hypochlorite is effective at reducing what?
endotoxin from the root surface
82
how often is sodium hypochlorite used today?
rarely
83
what are the side effects of sodium hypochlorite?
* odor
* fresh preparation
* corrosive
* bleaching
84
which topical antimicrobial effects plaque and gingivitis due to tin ion aggregation and metabolism?
* SnF2 (gel-kam)
* this results in a significant anticarogenic effect
85
describe the benefits of SnF2 as a topical antimicrobial
* reduction in gingivitis but not in plaque scores
* limited benefits as subgingial irrigant
86
what is Keyes's technique?
* the use of baking soda, NaCl, and H2O2 as a topical antimicrobial
* showed no significant differences compared to other topical antimicrobials
* the difference lies in the correct brushing mechanism
87
describe triclosan as a topical antimicrobial toothpaste
* broad spectrum antimicrobial
* soaps (dial) and antiperspirants
* colgate total
* only toothpaste with ADA seal for plaque/gingivitis reduction
88
describe the contents of colgate total
* 0.3% triclosan
* 2% PVM/MA copolymer polyvinyl methyl ether and maleic acid, Zn citrate, pyrophosphates
89
describe the mechanism of action of triclosan
* primary site of action is in bacterial cytoplasmic membrane
* prevents essential amino acid uptake causing cell leakage of contents
90
describe the side effects of triclosan
* no development of resistance
* no adverse effects on hard/soft tissue
* has an anti-calculus effect fromt he copolymer
* may also add anti-tartar ingredient (pyrophosphate)
91
describe research conducted on triclosan
* 29% reduction in gingivitis
* 17-25% reduction in supragingival plaque
* 47.6% fewer sites with severe gingivitis
92
describe biotine
* glucose oxidase, lactoperoxidase, and lysozyme
* biotene dry mouth toothpaste, dry mouth gum, and gentle mouthwash
* oral balance moisturizing gel and dry mouth liquid
* alcohol-free
93
biotene is alcohol-free. why should it not be used with other rinses that contain alcohol?
alcohol destroys antimicrobial enzymes in biotene
94
studies have not documented effectiveness of ___ in the treatment of periodontitis
topical chemical plaque control agents
95
describe supragingival irrigation
* delivery coronal to the gingival margin (90\*)
* patient/professional
96
describe marginal irrigation
* delivery is angled apically to the FGM (45\*)
* patient/professional
97
describe subgingival irrigation
* deliver is in the sulcus/pocket
* professional/patient
98
decribe rationale for irrigation
* flush away bacteria
* LPS is loosely adherent
* non-specific reduction of microbes
99
what is the depth of penetration with mouth rinsing?
4% pocket depth
100
what is the depth of penetration of supragingival irrigation?
* 29-71% of shallow pockets
* 44-68% of moderately deep and deep pockets (3-4mm or less)
101
what is the depth of penetration of subgingival irrigation?
75-93% pocket depth
102
describe hydrokinetics and water pressure of supragingival irrigation
* pulsating stream with compression and decompression phases
* decompression facilitates displacement of debris and bacteria
* 80-90psi can be tolerated by human gingival tissues
103
describe the supragingival irrigation technique
* twice daily
* start at lowest pressure setting
* aim jet across proximal papilla for 10-15 sec
* trace along gingival margin to the next interproximal papilla
* should use the full reservoir
* use from buccal to lingual surfaces
* not a substitute for toothbrushing and flossing
104
describe supragingival irrigation with water as a monotherapy
* results varied for plaque removal and reduction of plaque indices
* irrigation with water inferior at attaining or maintaining health
* do not use in lieu of toothbrushing
105
supragingival irrigation with water or a placebo combine with toothbrushing is most beneficial for which patient?
* pt with gingivitis that perform inadequate interproximal cleaning
* pt with mild to moderate periodontitis
* routine OH plus irrigation associated with significant reduction of proinflammatory cytokines IL-1 and PGE2
106
describe supragingival irrigation vs rinsing with medicaments
* no conclusive data to show one method is superior to the other
107
describe subgingival penetration of solutions after supragingival irrigation
* most studies usually projected 3mm subgingivally
* gingival inflammation frequently diminished despite unchanged plaque levels
* possible due to diluting plaque toxicity, interference with subgingival plaque maturation, washing away of unattached plaque
108
subgingival penetration of solutions after supragingival irrigation is beneficial in treating ___ but not \_\_\_
gingivitis, but not periodontitis
109
describe the bacteremia of supragingival irrigation
* appears to have similar levels of bacteremia as toothbrushing, floss, periodontal dressing changes, SRP, and chewing
* no particular hazard to healthy patients
* risk unknown for patients that require premedication
110
who are likely candidates for supragingival irrigation?
* those with inadequate oral hygiene
* orthodontic patients
* gingivitis patients
111
describe methods of delivery of subgingival irrigation
* syringe - cannula with an end or sideport
* jet irrigator with cannula
* ultrasonic
112
what are limiting factors of subgingival irrigation?
* calculus
* lateral dispersion (even with ultrasonic)
113
\_\_\_ should precede subgingival irrigation
SRP
114
in subgingival irrigation, ___ should be utilized to avoid projecting bacteria into tissues
low irrigation forces
115
for subgingival irrigation, is there a difference in end port or side port cannula?
no
116
for subgingival irrigation, how far should the tip be inserted?
3mm
117
describe subgingival irrigation and SRP
* controversial
* currently insufficient data to indicate routine use to augment SRP
* recent data using high concentration and prolonged multiple applications of antimicrobials show promise
118
describe chlorhexidine as a subgingival irrigant with ultrasonics
* no significant difference than with H2O
* possible difference in pockets 4-6mm but not in pockets \>7mm
119
describe iodine as a subgingival irrigant with ultrasonics
* possible enhanced effect in pocket depths \>7mm
120
what are limitations to subgingival irrigation with medicaments?
* short half-life of injected solutions
* minimal dispersion (use circumferentially)
* CHX reduces quickly when introduced subgingivally; contact with blood inactivates CHX
* gingival crevicular fluid flows outward
* little contact time with subgingival microflora
121
describe methods of delivery of professional irrigations
* hand syringe ok but can cause damage to tissues
* forces up to 80-90psi can be tolerated by tissues, but a safe level is at about 20psi
* hand syringes can deliver pressure 10-20 times this, making it easier to damage tissue
122
in professional irrigation, ___ irrigators have been shown to be more effective
* jet
* they deliver the H2O or medicament in a pulsating manner
* pulsating jet irrigators have a built-in tissue decompressing phase
* constant tissue compression, as seen with syringe irrigators, can block proper plaque displacement
123
describe what to use with home irrigation
chlorhexidine, listerine, or fluoride
124
is there a benefit to home irrigaiton?
* yes, likely
* benefits are from daily delivery
* patient can become a co-therapist
125
describe the requirements for locally delivered chemotherapeutic to be considered effective
* the drug must **reach** the base of the pocket, where disease activity is
* the drug must be delivered in high enough **concentrations** to destroy the bacteria
* the drug must **stick around** long enough to demonstrate effective results
126
what are the advantages of locally delivered chemotherapeutics?
* sustained higher drug concentrations in the GCF
* better patient compliance/acceptance
* drug resistance has not become a problem
* site specific
127
describe the characteristics of minocycline microsphere polymer
* bioadhesive
* no retentive dressing necessary
* bioresorbable
* hydrolyzes to CO2 and H2O - nothing to remove
* proven safety
* suture material
128
what is minocycline?
potent, broad spectrum antibiotic
129
minocycline is a semi-synthetic derivative of \_\_\_
tetracycline
130
minocycline is effective against what 3 periodontal pathogens?
* p. gingivalis: MIC = 0.06 mcg/ml
* p. intermedia: MIC = 0.25 mcg/ml
* a actinomycetemcomitans: MIC = 2.00 mcg/ml
131
minocycline microspheres achieve high ___ with minimal \_\_\_
* local concentrations
* systemic levels
132
microspheres vary in size from ___ to ___ microns, which confer their ___ \_\_\_ characteristics
* 20-60 microns
* sustained release
133
describe the PD reduction and increase in AL of the locally delivered chemotherapeutic, actisite
* PD reduction: 1.38 - 2.15
* increase in AL: 0.69 - 1.56
134
describe the PD reduction and increase in AL of the locally delivered chemotherapeutic, arestin
* PD reduction: 1.32 - 1.99
* increase in AL: N/A
* \*arestin is considered the "gold standard"
135
describe the PD reduction and increase in AL of the locally delivered chemotherapeutic, atridox
* PD reduction: 1.1 - 1.8
* increase in AL: 0.8 - 1.0
136
describe the PD reduction and increase in AL of the locally delivered chemotherapeutic, periochip
* PD reduction: 0.95 - 1.16
* increase in AL: 0.31 - 0.75
137
in minocycline microsphere clinical trials, the trial design was focused on treating \_\_\_
the whole mouth
138
describe the results of minocycline microsphere clinical trials
* 60% of responding site treated with minocycline microspheres and SRP exhibited probing depth reductions of 2mm or more versus SRP alone
* patients treated with minocycline microspheres and SRP maintained a \>1.5mm reduction in pocket depth over 12 months
139
clinical trials showed that minocycline microspheres and SRP delivered enhanced efficacy to a broad range of which difficult to treat sites and patients?
* molars
* furcation sites
* smokers
* elderly
* patients with CV disease history
140
describe the safety results of minocycline microsphere clinical trials
adverse events same as control group
* no antibiotic resistance
* no staining
* no taste alterations
* no GI upset
141
clinical trial results showed that minocycline microspheres and SRP is significantly more effective in ___ than SRP alone
reducing pocket depth
142
clinical trial results showed that the effect of minocycline microspheres and SRP is ___ with the baseline depth of the pockets
incremental
143
clinical trial results showed that repeated therapy with minocycline microspheres and SRP does what?
prolongs the efficacy
144
clinical trial results of minocycline microspheres showed what about ease of use, toleration, and safety?
they are very easy to use, well tolerated, and safe
145
what are the patient after-care instructions for the use of minocycline microspheres?
* do not brush for 12 hours
* avoid eating hard, crunchy, or sticky foods for one week
* postpone use in interproximal cleaning devices for 10 days
146
minocycline microspheres maintain their therapeutic concentration for up to ___ days
14 days
147
what is atridox?
* locally delivered chemotherapeutic
* doxycycline gel
* comes in two syringes or one pre-mixed
* subgingival controlled-release
148
with atridox, ___ may be packed into the pocket with a cord packer
overflow material
149
with atridox, perio dressing or adhesive may aid in \_\_\_, but it is not necessary
retention
150
after local delivery of atridox, patients may be instructed to remove residual material after what amount of time?
7 days, via toothbrushing and/or floss
151
what are the indications for atridox?
* chronic adult periodontitis
* gain in clinical attachment
* reduction in probing depth
* reduction in bleeding on probing
152
what are the contraindications for atridox?
* should not be used in patients who are hypersensitive to doxycycline or any other drug in the tetracycline class
153
what are the patient after-care instructions for the placement of atridox?
* patient should avoid brushing, flossing, and eating at affected sites for one week
154
describe the FDA approval of atridox
* FDA approved as a **monotherapy**, but **should** be used as an **adjunct** to mechanical treatment
* will not remove any calculus by itself
155
what is a chlorhexidine chip?
aka perio chip
* locally delivered chemotherapeutic that resembles a small chip and is placed subgingivally
156
describe storage of perio chip
can be stored at room temp
157
what should be done to improve the efficacy of perio chip placement?
* keep chip and tissues dry
* Mfgr claims improved formulation has improved handling
* pockets must be at least 5mm
* difficult in narrow pockets
158
after the placement of perio chip, patients should not brush or floss for how long?
7 days
159
T or F
local delivery systems are useful adjuncts, even if a site continues to break down after therapy
false
they should not be used if a site continues to break down
160
it is useful to re-evaluate a patient who receives a locally delivered system. describe
* 10 days to two weeks, if improvement, resume recalls
* if no improvement, reapply or refer
161
describe antibiotic therapeutic strategies from the early 70s
* treat periodontitis as a bacterial infection
* only a few specific organisms that needed to be targeted
* thought to be exogenous and could eliminate from the body indefinitely
* noteworthy successes
162
describe antibiotic therapeutics prescribed for perio treatment
* not respond to conventional mechanical therapy
* acute periodontal infections associated with systemic manifestations
* prophylaxis for medically compromised patients
* adjunct to surgical therapy
* adjunct to non-surgical therapy
163
describe the generation of protective antibodies in the regulation of immune/inflammatory responses
* immunization as a method to prevent periodontitis
* animal models showed reduction in alveolar bone loss
* successful vaccine problems
164
describe nitric oxide (NO) inhibitor in the regulation of immune/inflammatory responses
* PMN and macrophages release reactive oxygen species such as NO to kill bacteria
* released in excess initiate inflammation
* NO inhibitor decreased bone loss ligature induced periodontitis in rats
165
describe the primary MMPs involved in periodontal tissue degradation
* family of 17 metalloproteinases
* degrade ECM molecules
* collagen, gelatin, elastin
* good evidence participate in tissue deestruction and AL
166
describe inhibitors of MMPs
* chemically modified tetracycline and low-dose doxycycline inhibit activity of MMPs
* appear to be good candidates for inhibiting the destruction of periodontal structures
167
what is collagenase?
* a MMP
* breaks down collagen
* release is triggered by cytokines in response to bacterial endotoxins
168
periostat is targeted at elevated ___ levels found in periodontitis patients
collagenase
169
what is the indication for periostat?
* for use as an adjunct to SRP to promote attachment level gain and to reduce pocket depth in patients with adult periodontitis
