Systemic Antibiotic Therapy

Systemic antibiotics are drugs that, when given, affect the whole body. Normally they are administered in pill form when used in periodontal treatment. Periodontists use systemic antibiotics to treat acute infections, such as gum abscess (gum boil) and also before treatment when patients have certain medical conditions, such as mitral valve prolapsed. Systemic antibiotics are also recommended for two weeks after regeneration procedure and when implants are placed. This is done to make sure there is no infection during the early healing stages. After culturing, we use then to treat more aggressive gum infection.

Recently, there has been interest in the use of the low dose antibiotic, Periostat. The dose is so low the drug does not kill bacteria, but rather to change the way the body responds to infection by inactivating destructive enzymes called collagenase.

The objective of Periostat is to prevent the destructions of the tissue around your teeth by inactivating the destructive enzymes released by the bacterial infection. It does nothing to treat the actual cause of the infection since the dose is below the antimicrobial level for doxycycline. We think of this as similar to trying to prevent the destruction caused by a fire by spraying water on the back of the door. As soon as you turn off the water, the fire burning on the front door burns the house down. Our primary approach has focused for years on putting out the fire by reducing or eliminating the bacterial infection. This can include local and/or systemic antibiotics for seven to ten days, antiseptics, non-surgical or laser surgery care. In combination with your personal plaque control, this will work very well in almost all cases and is a better choice to save your smile.

There has been much interest in local antibiotic therapy. If an antibiotic can be delivered directly to the pocket, without the patient having to take systemic doses, there are far fewer side effects and fewer chanced of resistant bacteria forming. In addition, with direct local delivery, the concentration of the antibiotic at the diseased site can be 100 times greater than taking the medication orally. However, it is important to note that all local delivery antibiotics are recommended as adjusts to scaling and root debridement and not as stand-alone treatments. Systemic antibiotics are diluted before reaching the pocket. With local application, the antibiotic is interested directly into the pocket, resulting in much higher concentrations.

Recently a new, locally administrated antibiotic called Arestin was approved by the FDA for reduction of pocket depth and infection in periodontal disease. It contains minocycline, an antibiotic shown to be very effective in eradicating the bacteria which causes periodontal disease. Arestin delivers minocycline in a unique, powdered microsphere delivery system that is bioadhesive and bioresorbable. Fluid in the pocket causes channels to form inside the microsphere, allowing sustained release of antibiotic over 14 days.

Atridox is a unique delivery system that uses a gel which can be injected directly into a pocket. The gel hardens quickly and then slowly dissolves over the next 7 days, releasing doxycycline. The manufacturer claims that with this system the entire pocket is filled with the antibiotic, which may not be the case with fibers or chips. This appears to be an advantage although there are some researchers feel all three systems are effective because the antibiotic diffuse into the pocket fluid, even without direct contact.

PerioChip: PerioChip is a thin wafer that contains chlorhexidine. While chlorhexidine is not an antibiotic, it is a powerful antiseptic and kills most pathogens. The wafer slides under the edge of the gum into the pocket, a simple procedure that does not require anesthesia. The wafer dissolved over several days and does not have to be removed.

Generally speaking local delivery antibiotics are used in the periodontal Maintenance phase of therapy, when isolated areas of the mouth seem to be worsening. Their use is generally not recommended during the active phase of treatment. The effectiveness of these products is somewhat controversial and while there is usually some improvement, whether these results are long-term has yet to be demonstrated. Certain cases seem to respond better than others and your periodontists will help advise you whether these treatments may be beneficial in your particular case.

Its human nature to look for a quick and easy solution to any health problem and treating periodontal disease is no exception. Almost monthly, there is another claim of curing gum disease with a new drug, mouthwash or pill. Unfortunately, these cures do not work and by the time the patient discovers that, much more periodontal destruction has occurred. Patients can’t even trust most medical studies which seem to show fantastic results. Often the company selling the new product sponsors these studies and that same company is paying the dentists who are touting the results. Anecdotal results or short –term studies are simply not a sound basis upon which to base treatment. Most serious researchers believe there must be at least two “blind” human studies of 6 months or longer to warrant attention and longer-term studies to dictate therapy. Be aware of claims that periodontists don’t want to use a product because it would do away with the need for surgery. Any ethical dentist looks for the best health solution for his or her patients, regardless of profit margin and if you don’t feel that confidence with your dentist, you need to look into an alternative provider.

The following treatments often generate claims of cures that are either highly exaggerated or just plain false.

The gold standard for mouthwashes is chlorhexidine, commonly sold as the prescription mouth wash peridex. It is extremely effective in reducing plaque and we prescribe it frequently after active therapy. It is safe, but will stain teeth over time, which is of concern to most patients. (The stain is removed by simple polishing of the teeth unless it stains a leaking filling). Certainly we would rarely discourage its use by a patient. However, no mouthwash is able to penetrate to the bottom of a pocket will still contain plaque that produces more disease.

Mouthwashes are good adjuncts to therapy, particularly when flossing and brushing are limited, but they do not cure periodontal disease. Other mouth washes that are useful include PerioMed; a stannous fluoride mouthwash, and Listerine, a well studied rinse that helps reduce plaque.

For years, researchers have studied the effects of diet on periodontal disease. While there are numerous studies that indicate one supplement or another reduces or cured gum problems, none have been reproducible by objective researchers. Our current thinking is that those with normal, healthy diets do not improve their periodontal health with supplements.

In the last decade there has been an attempt to place antibiotics (Actisite, Arestin and Atridox) or antimicrobial (PerioChip) directly into the pocket. With newer techniques it is possible to have the product time-release over several days, which helps kill the bacteria in the pocket. We currently use these local delivery antimicrobials in the maintenance (recall) phase of treatment, when specific areas don’t seem to be doing well.

It has been known for many years that the antibiotic doxycycline not only kills bacteria, but also reduced collagenase and enzyme that causes breakdown of periodontal tissues. It was found that in low doses, when the antibiotic affect is no longer available, collagenase reduction still occurs. Because of the low dose, it is thought that the problems with side effects and bacterial resistance are greatly reduced and the drug can be used on a long-term basis. This attempt to increase patient resistance is the first step of what promises to be an important approach to maintaining periodontal health. Unfortunately the research on this specific product (Periostat) is extremely limited and the results are non-conclusive. In the only human study the difference between the control and the product was less than 1mm change in the pocket depth, which is not clinically significant. We use Periostat with certain cases that are resistant to conventional care, but it is not recommended at this time for the typical case.