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| Monday |
8:00 AM - 5:00 PM |
| Tuesday |
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| Wednesday |
8:00 AM - 5:00 PM |
| Thursday |
8:00 AM - 5:00 PM |
| Friday |
8:00 AM - 5:00 PM |
| Saturday |
Closed - Except Emergencies |
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Closed - Except Emergencies |
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| Antibiotic
Therapy
Systemic Antibiotic Therapy
Low Dose Antibiotics
Local Antibiotic Therapy
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 a gum abscess (gum boil), and also before treatment when patients have
certain medical conditions, such as mitral valve prolapse (See Prophylactic
Antibiotics). Systemic antibiotics are also recommended for two weeks
after regeneration procedures and when implants are placed. This is done
to make sure there is no infection during the early healing stages, which
are critical with these two techniques.
Because periodontal disease is an infection, it would seem logical that
antibiotics would eliminate the problem. Unfortunately, when treating
routine periodontal breakdown, the effects of antibiotics are short-lived.
This is because the bacteria that cause the disease reform immediately
after the antibiotics are discontinued. In fact, periodontal cleanings
done to remove calculus and plaque appear to be as effective as antibiotics
in controlling the infection.
As a rule, for most routine periodontal conditions, systemic antibiotics
are not necessary or even useful. In some advanced cases there may be
very specific harmful bacteria that can be eradicated with systemic antibiotics.
For these cases, a short-term treatment of antibiotics may be useful.
In cases where traditional treatment does not produce the expected results,
the mouth may be cultured to find out what specific bacteria are present.
This will guide the therapist on which antibiotic to use.
Because overuse of systemic antibiotics can cause patient sensitivity
and bacterial resistance, they should be used only when specifically indicated.
[back to top]
Low Dose Antibiotics
Recently there has been interest in the use of low dose antibiotics.
The dose is so low the drug does not act to kill bacteria, but rather
to change the way the body responds to infection.
One interesting effect of certain antibiotics is they not only kill the
bacteria that may cause periodontal disease, but they also reduce the
body's production of collagenase, an enzyme that destroys gingival tissues.
We all need some collagenase as older tissue is removed and replaced with
new tissue. However, in periodontal disease there seems to be an overproduction
of collagenase, causing the body to destroy healthy gum tissue. The antibiotic
doxycycline was found to combat these enzymes, even in doses so small
that there was not an antibiotic effect. The advantage of the smaller
doses is a great reduction in the chance of resistant bacterial strains
forming, and in fewer side effects.
Periostat is a capsule
of 20mg of doxycycline, and two clinical studies have shown that patients
who take 2 capsules daily have a reduction in clinical inflammation. The
studies were limited to 9 months, and so there is no official recommendation
to take the product for a longer period. From a practical standpoint it
seems that Periostat can be taken indefinitely. However, some preliminary
work indicates that there is a positive residual effect for 3 months after
stopping the drug, and so some practitioners recommend taking Periostat
three months on, three months off. The daily 40mg doses are so low as
not to qualify as an antibiotic, and there is no known effect on the pocket
bacteria. Thus Periostat must be used in conjunction with other therapies
that address bacterial removal. Indications for Periostat are generally
seen in recall patients who are not responding well, and have generalized
inflammation in spite of reasonable oral hygiene.
[back to top]
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[back to top]
Local
Antibiotic Therapy
Actisite
Atridox
PerioChip
Arestin
While systemic antibiotics have a very limited use in treating typical
periodontal disease, there has been much interest in local antibiotic
delivery. 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 chances 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 adjuncts to scaling and root debridement, and not as stand-alone treatments.
[back to top]
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Systemic antibiotics
are diluted before reaching the pocket. With local application, the antibiotic
is inserted directly into the pocket, resulting in much higher concentrations.
(click on image for a larger view) |
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A major difficulty with local antibiotics is keeping
the antibiotic at the site for the several days necessary to kill the bacteria.
Simply rinsing the pocket with antibiotics does little, and normal pocket
fluids flush the antibiotic out of a pocket in less than 2 minutes. This
is one reason that mouth rinses are so ineffective in the periodontal pockets.
In the last ten years four products have been introduced into this country
that allow prolonged drug delivery directly into the pocket. The first introduced
was Actisite, a string embedded with tetracycline, a drug known to kill
many of the bacteria that cause periodontal disease. The Actisite fiber
is placed in the pocket and left for ten days, and during this time high
concentrations of tetracycline are released. At the end of 10 days the string
is removed from the pocket. Over the next few days the inflammation will
subside, and the pocket will ideally shrink as the tissues tighten around
the tooth. The major difficulty with Actisite is that the string must be
removed, requiring a second appointment. Placement may cause some minor
discomfort, requiring a drop of anesthesia, but as with all local delivery
products, there is little or no discomfort while the product is in place.
[Back to top] |
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| Actisite Fiber |
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Model showing Actisite
fiber
packed under gum |
Model showing fiber
with
"gum" stripped away |
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Probe in 6mm pocket with
inflammation and exudate (pus) |
Three months after Actisite, pocket
reduced to 3mm without inflammation |
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Pocket with draining abscess
and severe inflammation |
Three months after Actisite, no
inflammation or bleeding on probing |
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[Back to top]
Atridox is a registered
trademark of Block Drug Corporation.
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 who feel
all three systems are effective because the antibiotics diffuse into the
pocket fluid, even without direct contact.
The product comes in two syringes, one containing
450mg of a liquid polymer, and the other 50mg of doxycycline hyclate,
an antibiotic effective against most periodontal pathogens. The syringes
are interlocked together, and the contents mixed vigorously.
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| Syringes containing liquid polymer and
doxycycline |
Mixing contents of the two syringes |
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| Inserting canula
(blunt needle) to prepare for placement |
| Following mixing, a canula is placed
on the syringe containing the Atridox, and the material is injected under
the gum into the pocket. This generally requires no anesthesia. |
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| Atridox being
injected into periodontal pocket |
Atridox sets rapidly on contact with crevicular fluid or blood, and quickly
takes on a wax-like consistency. This allows the material to remain in the
pocket for 7 days, during which time it dissolves, slowly releasing the
antibiotic.
To help prevent the product from extruding from the
pocket, cyanoacrylate ("super glue") may be applied to the
gum margin. In some cases a periodontal dressing is placed to help retention.
The patient should refrain from brushing and flossing this area for two
weeks. During that time chlorhexidine mouthwash is generally recommended.
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| Cyanoacrylate glue being applied |
Periodontal dressing covering pocket |
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| Studies have shown decreased probing
depth, reduced bleeding, and improved attachment levels when Atridox is
used in conjunction with scaling and planing. |
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| Pocketing and bleeding on probing |
Pocket reduction and lack of bleeding
after Atridox |
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| [Back to top]
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 dissolves over several days,
and does not have to be removed. [back to top]
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| PerioChip ready
to slip under gum into pocket |
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[Back to top]
The most recent local antibiotic therapy introduced consists of small
spheres of minocycline, a derivative of tetracycline. This drug, similar
to the ingredients in Actisite and Atridox, is very effective in killing
the bacteria that are thought to cause periodontal disease. The primary
advantage of this new product is the ease of use. The spheres, which
look like a fine powder, are contained in a small blunt plastic needle,
and are injected into the pocket. This requires no anesthesia. The spheres
are bioadhesive, and stick to the pocket wall where they slowly release
minocycline over a 14-21 day period. Because the spheres are also biodegradable
they do not require removal.
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Delivery syringe containing Arestin (minocycline)
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The plastic syringe consists of a cap,a plunger, and the Arestin,
which is expelled by the plunger
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Close-up of Arestin powder being expelled from
syringe tip
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Arestin being expelled under the gum and into the
periodontal pocket
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[Back to top]
Generally speaking local delivery antibiotics are used in the
Periodontal Maintenance phase of therapy, when isolated areas of the
mouth seems 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
seems to respond better than others, and your periodontist will help advise
you whether these treatments may be beneficial in your particular case.
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