The Use of Systemic Antibiotics in the Treatment of Periodontal Diseases.

 

Paradigm Shift in the Management of Adult Periodontitis.

This issue will affect your office's perio program. In 1996, The American Academy of Periodontology puplished a "Position Paper" entitled "Systemic Antibiotics in Periodontics" It was published in the Journal of Periodontology and can be found in volume 67:831-838. The paper urges restraint when prescribing antibiotics for periodontitis.

The article is full of supporting references and has dramatically affected some of our treatment protocols. In this newsletter, I will outline the major thrusts of the paper and then describe what we are doing in light of this information.

The paper stresses the following 5 points:

1. Periodontal pockets almost never have only one pathogen residing. Typical strains may include the following bacteria:
a. Actinobacillus actinomycetumcomitans
b. Porphyromonas gingivalis
c. Bacteriodes forcythus
d. Treponema denticola
e. Prevotella intermedia
f. Eubacterium nodatum [top]

2. Because of the pathogen mix, it is highly unlikely that prescribing any one single antibiotic will be effective in eradicating the flora.

3. The emerging resistance among oral and medical pathogens to common antibiotics dictates a restrictive and common sense conservative use of systemic antibiotic therapy.

4. Patients with gingivitis or stable adult periodontitis usually respond well to mechanical periodontal therapy alone and derive little or no additional benefit from antibiotic therapy.

5. Systemic antibiotic therapy for periodontal therapy should be reserved to the following:
a. patients with medical problems requiring antibiotic coverage.
b. juvenile periodontitis
c. patients with severe/acute periodontal infections.
d. patients who are refractory and have continued to breakdown in spite of thorough root debridement and excellent home care.

Previously, we have used systemic antibiotics, most commonly Doxycycline, with patients in the maintenance phase of therapy if they showed signs of returning inflammation. Additionally, we have used Doxycycline in "pulsed dose deliveries" for our bone regenerative patients.

Wherever possible, we will avoid the use of systemic antibiotics in the control of routine adult periodontitis and rely instead upon stressing excellent oral hygiene and the use of topical agents contained in rinses and pastes. I urge your practice to adopt the same approach in your soft tissue and maintenance programs. [top]

Chemical Agents for Control of Plaque and Gingivitis.

Literally hundreds of journal references exist reporting the findings of studies which investigated the efficacies of topical agents with respect to reductions in plaque and gingivitis. Another position paper by The American Academy of Periodontology discusses the research data on chemical agents. Some of the more important ones are synopsed below.

Pre-Brushing Rinse (Plax)- multiple studies have shown that there is no advantage with this product when compared to placebos.

Fluorides- Multiple conflicting results have been reported with regard to plaque levels and gingivitis therefore the AAP suggests that fluorides be used only as an anticariogenic agent.

Sanguinarine(Viadent)- multiple research findings are equivocal. Questions are raised about the long term safety of the extract. We have not seen significant results in our patients on Viadent. [top]

Quarternary Ammonium Compounds (Scope and Cepacol)- Multiple studies have shown plaque reductions of 25 to 35%, but reports on gingivitis reductions are equivocal. We note some benefit with these rinses, however alcohol content is up to 18%.

Triclosan- Just approved for use in USA. Data shows significant reductions in plaque and gingivitis.

Chlorine dioxide (Oxyfresh)- Multiple studies confirm excellent efficacy for halitosis. It is in phase 2 FDA clinical trials for gingivitis efficacy. Some studies also reported pocket reductions and significant improvements with bleeding on probing.Our office is participating in this exciting research and the early results are promising. Oxyfresh is mostly distributed by dental offices and if you are interested in offering them to your patients, please Email me at 73302,554 @Compuserve.com. I will be happy to work with you to effectively implement this into your preventive and halitosis management programs.

Phenolics (Listerine)- Multiple studies confirm 35% reductions in plaque levels in the absense of any brushing or flossing and significant improvements in gingival status are seen. This product carries the ADA seal for plaque and gingivitis. The only disadvantages are taste complaints and the 26% alcohol.

Chlorhexidine gluconate (Peridex or Perioguard)- These are the most effective prescription products available to us for reducing plaque and gingivitis. They both are FDA and ADA accepted. Multiple studies confirm clinical benefits. We use these for short term assistance during bone regeneration cases. Disadvantages include taste disturbances, staining, increased calculus formation and it is inactivated by sodeium lauryl sulfate, a majore ingedient in most dentifrices. The manufacturer's advise waiting 30 minutes after brushing before rinsing and this has been a compliance problem. [top]

Irrigation

Supragingival irrigation has long been recognised as clinically beneficial especially when medicaments (Chlorhexidine, Listerine or Oxyfresh) area diluted. Improvements are seen with microbiologic and gingivitis studies. Gingival inflammation has been reduced up to 62% in some studies. We are prescribing oral irrigators for any patient with difficulty in interproximal plaque control. Again, this shift in philosophy relates directly to our hesitancy in prescribing systemic antibiotics when inflammation is returning. Reports on subgingival irrigation are conflicting and thus it remains controversial, especially when done as a single, in office delivery. This is largely due to the fact that the gingival crevicular fluid washes the medicaments from the pockets too rapidly. Therefore "gels" may be of greater benefit due to the "substantivity" during office use. A chlorine dioxide gel (Oxyfresh) is being used in this manner. Other gels are in development.

For information on where to obtain any products contained in this page go to help on Selecting Oral Care Products.

Hopefully this review of the current literature describing the philosphy shift will help you in your perio programs. [top]