Too little too late

Each New Year brings with it the hope that things will be different. On New Year’s Day, many of us committed to the usual resolutions such as losing weight or paying off credit cards.

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Each New Year brings with it the hope that things will be different. On New Year’s Day, many of us committed to the usual resolutions such as losing weight or paying off credit cards. January and February have come and gone, and either we stuck to the resolutions or we placed them on the back burner until 2007.

As a practicing clinician, I like to start off each New Year by making a few changes in the way I practice. I try to concentrate on the result I want and give it my all. This year I’m going to change my nonsurgical periodontal therapy protocol, and I’ll tell you why and how I plan to do things differently.

I began to think I needed to modify my approach to therapy in the fall of 2005 when I sent for and listened to a CD from the 91st Annual Meeting of the AAP in Denver. The presenter was Dr. Christopher Cutler, an associate professor at Stony Brook School of Dental Medicine. The title of Dr. Cutler’s presentation was, “Antigen Presenting T-Cell Pathogenesis.” The topic fascinates me because of the continuing discoveries about the host inflammatory/immune response to microorganisms in periodontal infections. Dr. Cutler began his lecture by reminding the audience that most periodontists work in an age of “repair” because the initial therapy patients receive is “too little too late.” Yes, Dr. Cutler acknowledged the importance of initial therapy to reduce the microbial challenge, but his message was one that I thought about long and hard.

In reviewing the literature on the effectiveness of SRP (mechanical debridement), this common nonsurgical therapy consistently reduces inflammation and pocket depth and increases attachment level. (Remember, however, that mechanical debridement may cause loss of attachment in shallow pockets less than or equal to 3 mm.1)

In making evidence-based decisions on the application of antimicrobials to enhance mechanical debridement, I chose to review the evidence on systemic antibiotics and subsequently changed my nonsurgical protocol in 2006. Antibiotics (locally delivered and systemic) can kill or inactivate bacteria that are inaccessible to mechanical debridement.1 Locally delivered and systemic antibiotics can enhance the effects of mechanical SRP, reduce the risk for refractory disease and, most important, reduce the number of teeth that need periodontal surgery.1 In delivering adjunctive therapy (pocket disinfection) through the use of locally or systemically delivered antibiotics to compliment mechanical debridement (pocket cleaning), I decided to become an adjunctive therapy sleuth and search for the truth. In this month’s column, I focus on the use of systemic antibiotics as adjuncts to SRP. I found the truth after pouring over the literature and talking to periodontal researchers, practicing periodontists and hygienists. I focused mostly on strong evidence found in systematic reviews, and I found what I needed in several publications.

For starters, I decided to re-read a chapter in the Annals of Periodontology, Volume 8 (1) titled, “2003 Workshop on Contemporary Science in Clinical Periodontics.”2 I found strong evidence that systemic antibiotics do improve attachment loss in the treatment of chronic and aggressive periodontitis. I also read several other significant articles, including those by well-known researchers Drs. Jorgen Slots and Walter Loesche.3,4 Dr. Loesche was more than happy to talk to me about his many years of periodontal research.

We discussed one of his many clinical trials that measured the nonsurgical treatment outcomes of patients with periodontal disease after 6.4 years of treatment.5 Dr. Loesche was adamant in his opinion that periodontal disease is an opportunistic infection that is mediated by host response to an overgrowth of mostly anaerobic bacteria in dental plaque. His views are supported by strong scientific evidence. In this particular clinical trial, subjects were selected based on an advanced periodontal infection that would normally require surgical intervention, i.e., an average of 8.7 teeth per patient. Subjects were diagnosed with an anaerobic infection based in part on a positive BANA test, which examines dental plaque for the presence of three common anaerobes. All subjects and all teeth were debrided by a periodontist/hygienist team during three to five visits. After initial debridement, patients were randomly assigned to receive metronidazole (500 mg twice daily), doxycycline (100 mg daily) or placebo tablets for two weeks. Patients went into a maintenance phase of treatment if none of their teeth required surgery.

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Patients who required surgery on one to six teeth were treated with locally delivered antimicrobial agents. Patients who had more than six teeth requiring surgery were retreated with systemic agents. Of the 90 subjects who completed the initial debridement protocol, 73 had no surgical needs, 17 had some teeth requiring surgery/extraction, and 14 of the 17 who required surgical treatment refused treatment and entered the maintenance phase. Some subjects were lost during the 6.4-year clinical trial, but it was still possible to make four important observations:

• The initial therapy in all groups reduced surgical needs by about 85 percent.

• A history of smoking served as a significant predictor of surgical relapse.

• Systemic antibiotics administered during the clinical trial resulted in a significant reduction in surgical needs. Sixty-nine percent of teeth needed neither extraction nor surgery.

• Non-responsive teeth were typically multi-rooted and repeated mechanical debridement increased surgical needs in some patients. Dr. Loesche has suggested that inadequate access to the root surfaces of multi-rooted teeth was an important aspect to the adverse affect of debridement in certain cases.

Loesche, et. al, made an important point, which is that inadequate SRP of furcations and increased nutrient availability resulting from bleeding could promote the continued growth of periodontal pathogens on these surfaces. The host would then respond, in kind, to the continued microbial challenge in these areas by continuing to battle the anaerobes with the body’s immuno/inflammatory response. Bone loss is the direct result of our body’s defense mechanisms against these nasty bugs.

So how can we modify our nonsurgical therapy protocols to accommodate what we now know about periodontal microorganisms and the host’s immuno/inflammatory response? Can we manage more severe types of periodontitis in a cost-effective, nonsurgical manner? Hygienists everywhere need to remember that we can make a difference in our patient’s lives. By diagnosing and treating periodontal infections early and nonsurgically based on evidence, we can reduce our patients’ surgical needs. We can recommend the administration of systemic and locally delivered antibiotics during initial therapy, and we can even test plaque samples to determine the appropriate systemic antibiotic. Table 1 shows the relative cost analysis of different types of microbial testing. The BANA test identifies some of the more virulent, anaerobic periodontal pathogens, and laboratory microbial testing, although much more expensive, can be useful in patients suffering from aggressive or refractory periodontitis.

Back to my New Year’s resolution: I resolve to use adjunctive therapies, including locally delivered and systemic antibiotics, to complement mechanical debridement (SRP), especially in cases with significant inflammation and deep pocketing. I will also recognize the anti-inflammatory component of care that mandates host modulation in high-risk patients. When selecting a systemic antibiotic, a high dose, short-term antibiotic is preferable.

Instead of offering patients initial therapy that is “too little too late,” hygienists should identify cost effective and safe chemotherapeutic means to control periodontal infections. Also, hygienists should develop a good working relationship with a local periodontist and continue to learn more about microbial testing and systemic antibiotic selection. We need to continue our education alongside the periodontist, and possibly find one as a mentor. Sometimes periodontal surgery complements nonsurgical therapy, and periodontists are not the enemy. The lack of commitment by hygienists and dentists to periodontal disease prevention, early diagnosis and treatment, and ongoing continuing education is enemy No. 1!

References:

1. van Winkeloff AJ & Winkel EG. Microbiological diagnostics in periodontics: biological significance and clinical validity. Periodontology 2000; 39: 40-52. 2005.

2. American Academy of Periodontology: Annals of Periodontology. Workshop on contemporary science in clinical periodontics 2003; 8(1): 115-181.

3. Slots J. Selecton of antimicrobial agents in periodontal therapy. J Periodont Res 2002; 37: 389-398.

4. Loesche WJ & Grossman NS. Periodontal disease as a specific, albeit chronic infection: diagnosis and treatment. Clinical Microbiology Reviews Oct 2001: 727-752.

5. Loesche WJ et al. The nonsurgical treatment of patients with periodontal disease: results after 4 years. General Dentistry. July/August 2005; 298-306.

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