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Antibiotics and antibiotic delivery systems
Recently, something of a “revolution” has happened in the treatment of periodontal disease. The fact that the basic cause of all periodontal disease is the body’s over-reaction in response to bacterial infection from plaque buildup has spawned a great deal of research into antibiotic therapies that can help to eliminate the disease, (preferably without the necessity of root planing, surgery or, preferably, even brushing the teeth).
Most dentists, especially periodontists (gum specialists) have found that antibiotic therapy has been helpful as an adjunctive therapy in addition to root planing and good daily hygiene, but has been less successful (the effects being quite temporary) when used by itself without proper debridement, or if the patient does not perform meticulous home care.
The most obvious reason for the futility of the use of antibiotic therapies without professional help and daily hygiene is that the antibiotics cannot be kept up indefinitely due to cost and side effects, and, in the absence of mechanical debridement and meticulous home care, any benefit gained from their use is lost soon soon after the antibiotics are stopped. Another reason is that the bone lost from the disease is never replaced, and the ill formed anatomy of the gums combined with the continued presence of the splinter-like calculus adhering to the roots continues to harbor bacteria regardless of the antibiotic dose applied. Good hygiene can overcome these obstacles. Chemicals cannot.
Doxycycline (minocycline) is a long acting form of tetracycline. Even though it is taken orally, it has an affinity for dermal structures so it tends to concentrate in the skin, teeth and gingiva. Doxycycline has both antibiotic properties and the ability to block the action of collagenasewhich is an enzyme that is produced by plaque organisms and is partly responsible for the dissolution of the connective tissue which makes up gum tissue. Many dentists who treat gum disease use it in conjunction with root planing for a period of ten days after each session to help the body recover from the procedure and to reduce the population of plaque organisms around the tooth roots during healing. If the patient reciprocates with very good daily hygiene, the root planing, combined with the doxycycline can bring about excellent healing. Total elimination of the disease may result provided that the patient is willing and able to clean all areas around each tooth. The regimen used is Doxycycline 100 mg; two capsules the first day, then one capsule once a day for another nine days. Some dentists prescribe one capsule twice a day instead. The patient must be aware that the use of any of the tetracyclines will make him or her very sensitive to sunburn for as long as he takes the drug plus several weeks thereafter. Some patients experience severe gastrointestinal upset from this drug. Doxycycline is often used in combination with metronidazole (Flagyl) to further increase its effectiveness.
The bacterial flora in plaque varies from patient to patient. In other words, every periodontal patient harbors different combinations of bacterial species which will stimulate his/her immune response. The immune response, in turn, causes the bone loss. If the dentist can eliminate the specific bacteria, he/she can eliminate the immune response, and this, in turn, stops (or at least slows down) the bone loss.
It has been found that analysis of a patient’s saliva can reveal the DNA of the specific organisms causing the immune reaction that is destroying that patient’s bone. DNA testing can ferret out bacterial species that are difficult or impossible to culture by ordinary means. This has opened up new avenues in patient-specific antibiotic therapy. At least one lab that I know of offers this service.
The analysis returned by the lab tells the practitioner exactly which pathogens are present, the clinical significance of each pathogen, and suggests patient-specific combinations of antibiotics which can be used to treat otherwise intractable periodontal infections. The test consists of having the patient rinse for 30 seconds with the sterile saline provided in the kit, and then expectorating into a shipping container which is then sent to the lab. Neither the kits, nor the lab fees are expensive, and the the lab provides everything the practitioner needs. The result is a pathogenic diagnosis and antibiotic treatment regimen for that specific periodontal patient. Practitioners should visit the website of Oral DNA Labs for more specifics and a look at a sample lab result sheet.
The same lab can use a saliva sample to test for the interleukin-1genotype. Interlukin-1 is a key regulator of the inflammatory process, and is a genetic marker in persons who may exhibit a hyper-responsive inflammatory reaction. This salivary test is said to predict the genetic propensity of individuals to periodontal disease and also predicts the severity of the disease if left untreated. Approximately 35% of the population possesses the genetic interlukin-1 marker, and these people are prime candidates for more severe bone loss associated with their periodontal disease. This test can also be used on young people to predict which ones will be more susceptible to periodontal disease later in life. (Note also that these tests are beginning to be recognized as genetic markers pertaining to cardiovascular disease as well.)
Arestin is a form of antibiotic that is actually injected into a periodontal pocket in order to kill off the bacteria that live there. (Bacteria are the ultimate cause of periodontitis.) It is generally used in pockets which are not easily reached with normal home cleaning aids. Arestin is by far the most popular antibiotic therapy now in use by dentists as an adjunct to the treatment of periodontal disease. Arestin is a viscous form of tetracycline (actually Minocin) unique because of its pharmacological preparation which consists of micro spherical particles. This formulation allows a very slow timed release of the antibiotic which increases the drug’s overall effectiveness. Its germ killing activity persists for up to 28 days after it is introduced into a periodontal pocket. The suppression of bacterial activity in the pocket for almost a month gives the body plenty of time to heal. Arestin has become a very important therapeutic tool in the treatment of periodontal disease.
Atridox is similar to Arestin, but its pharmacological preparation does not include micro spheres of the drug. It too is a method for delivering doxycycline. It is applied as a gel that conforms to the teeth and gums and then solidifies. Its effects are less long lasting than Arestin, but lasting enough to be of use during the healing phases after surgery. Once again, it is a professional adjunct that can be helpful after a thorough debridement of the tooth roots, and is especially helpful in cases where systemic doxycycline cannot be used because of its gastrointestinal effects. Both Atridox and Arestin are much more expensive than oral doxycycline because they are dentist-intensive.
Periostat is a proprietary product which is composed of a very low dose of doxycycline. It is taken twice a day for a period of three to twelve months (unlike doxycycline 100 which is taken once or twice a day for ten days) and is used principally for its inhibition effect on collagenase since the dose is too low to effectively act as an antibiotic (i.e.. to kill germs). Collagenase is an enzyme secreted by bacteria which breaks down the connective tissue which is an integral part of the periodontal apparatus. Periostat has been heavily advertised to the public, and for this reason is popular with some general dentists. It is a treatment alternative to higher doses of doxycycline, or combinations of drugs such as clindamycin and doxycycline, which are used in short term therapy for their bactericidal properties. Some dentists prescribe Periostat for one to two weeks before initial debridement to reduce bleeding and improve the outcome.
Actisite is a thin thread similar to dental floss, which is treated with tetracycline hydrochloride. This thread is placed by the treating dentist into the periodontal pockets around the roots of the teeth after a root planing, or sometimes after other surgical procedures. It is sometimes kept in place by the use of “super glue” (which, believe it or not, was originally developed as a biological/surgical adhesive.) This thread is left in place for ten days and then removed (super glue is water soluble). It has been shown to be helpful (but not essential) after aggressive dental cleanings.
Peridex (vs. Listerine)
Peridex is a prescription mouth rinse that is used by a patient at home to kill plaque organisms. It contains a disinfectant called chlorhexidine which is very effective against plaque organisms and has been shown to remain effective in the mouth for several hours after it is used. When first introduced, it was hailed as a great innovation in the treatment of periodontal disease. However, enthusiasm for it waned as it became apparent that its beneficial effects were inhibited by the simple use of ordinary toothpaste, and even worse, it caused a buildup of brown stain which, if left in place simply added to the buildup of foreign material on the root surfaces. It is still used for short term therapy, especially as an aid to reduce gingivitis prior to a dental scaling and as a method of disinfecting the mouth before surgical procedures. It turns out that Listerine mouth rinse is almost as effective in killing plaque organisms as chlorhexidine and has the advantage of being sold as a generic. It is also available without a prescription and is much less expensive, especially in generic form. It also does not stain the teeth. Unfortunately, the taste can be quite a deterrent!
PerioChip is a tiny wedge of material which is permeated with chlorhexidine and is placed in deep periodontal pockets as a method of sustained release of medication. It has been shown to be somewhat effective in the treatment of acute situations, but periodontists who I have spoken with have little confidence in its efficacy. In this form, the chlorhexidine is concentrated in specific areas and the staining properties are not important.
Plax is one of the most heavily marketed dental cleaning aids in American culture. Unfortunately, there is little evidence that rinsing with Plax, (or even “advanced” formula Plax) is any more effective in removing dental plaque (or in treating any dental disease) than rinsing with slightly soapy water. While it has absolutely no use in professional dentistry, it has been remarkably successful in enriching the company that manufacturers it, Warner-Lambert.