Trisha E. O`Hehir, RDH
If you haven`t had patients wanting antibiotics instead of periodontal treatment, you soon will. A study published in the May 1996 issue of "Oral Surgery, Oral Medicine, Oral Pathology" was the subject of a news release by the National Institute of Dental Research (NIDR), which sponsored the project. The NIDR news release ended with these comments, "...antimicrobial treatment is likely to be successful for most people with advanced gum disease for whom surgery is initially recommended. The regimen offers a cost-effective alternative to traditional surgical treatment for periodontal disease."
Based on this conclusion, the general public and newspaper journalists will lump all periodontal treatment into one basket and accuse periodontists and, by association, dental hygienists of taking advantage of them solely for financial gain. The news release convinced at least one journalist that taking an antibiotic was exactly the same as undergoing expensive, painful periodontal therapy.
Following release of the NIDR study, an article appeared in the Washington Post titled, "Antibiotics may allay gum problems. Study suggests most surgery can be avoided." To their credit, a bit was tagged on the end to suggest that periodontists were warning the public against misinterpretation of the study findings. However, these concerns were never mentioned. The newspaper article instead stressed the benefits of oral metronidazole as well as local delivery of antimicrobials.
The journalist pointed out that treatment with metronidazole reduced the need for surgery or extractions by 88 percent. Sounds impressive, doesn`t it? Before we accept a newspaper article as scientific evidence, let`s take a closer look as a consumer and as a dental hygienist.
The newspaper says it`s cheaper
Consumers reading this article will compare traditional treatment - specifically the preliminary scaling and root planing, which as quoted in the article at $1,500 in the Washington, D.C., area - to the idea of simply taking antibiotics for a week or two. It is no surprise that consumers would quickly ask about antibiotics rather than traditional treatment. According to the article, periodontists can be accused of pushing expensive, painful surgery rather than more conservative options, such as antibiotics. Consumers will read this and be assured that rich periodontists are taking advantage of them.
A quote by Dr. Walter J. Loesche, one of the researchers on this study, adds fuel to the fire by stating that periodontists will be unhappy with this study because "...any dentist who knows what he is doing can implement it. Any dentist is licensed to do it." The "it" referred to in the quote is prescribing antibiotics. However, Dr. Loesche is referring to much more than simply dispensing pills, an important point missed by the newspaper journalist.
The newspaper article fails to mention that patients in the study received four to five hours of debridement therapy by either a periodontist or a dental hygienist. Suddenly, the story changes. Unfortunately, the newspaper article only talks about antibiotic therapy, never mentioning debridement as part of the regimen. Three quarters of the way through the article, a single sentence ties debridement into the picture by stating that this new course of antibiotics should be done in conjunction with thorough cleaning above and below the gum. That`s all.
I`m going to ask my hygienist about this
Reading this article as a consumer with periodontal disease, I would be convinced that metronidazole alone could cure my periodontal disease. I would ask for a prescription at my next dental visit. Now it`s your turn as the dental hygienist to answer this request.
Reading the newspaper article as a dental hygienist, my first reaction was, "Who is writing this?" The journalist, for example, states, "...bacteria gather in pockets in the gums, hardening into a substance called plaque that can kill gum tissue and undermine support for the teeth." From that statement, I was sure he didn`t really have a complete understanding of the situation. If he didn`t know the difference between plaque and calculus, what else didn`t he know?
The journalist`s primary source of information was the news release from NIDR. The news release began with this sentence: "Persons with severe periodontal disease may be able to avoid surgery by taking antibiotics, a new study shows."
No wonder the journalist interpreted the findings as he did. Debridement was not mentioned until well into the second page of the news release, stating only that "... study participants underwent thorough debridement..." You and I know what "thorough debridement" is when discussed among periodontists and dental hygienists, but what do you think that term means to the general public? A "cleaning" perhaps?
Not as simple as it looks
The newspaper article and news release made treatment sound as simple as taking or not taking metronidazole. So I went to the original research article and found some interesting points. The research study was actually quite complicated, involving five levels of treatment with examinations by two periodontists every four to six weeks. Following several visits for debridement therapy, patients were given one of three medications: metronidazole, doxycycline, or a placebo.
At the next examination, those with more than six teeth still needing surgery or extraction - according to the criteria of pocket depth of 5 millimeters and bleeding, mobility, or furcation involvement - were given an additional two weeks of either metronidazole or doxycycline. Those with six or less teeth still needing surgery were treated with local delivery using one of the three options: ethyl cellulose films containing metronidazole, chlorhexidine, or a placebo. Patients were given up to two rounds of oral antibiotics and as many as three rounds of local delivery.
Have I lost any of you yet on this research protocol? It seems that these patients didn`t just take an oral antibiotic. They were seen as many as 10 times in addition to the initial several appointments for debridement therapy. They were examined by two periodontists at each stage of therapy and then seen by the treating clinician at each of the five stages over a span of one year.
This is the revolutionary new treatment which has been kept from patients! Sounds to me like the researchers have been living in a vacuum for the past few years if they think this is "new" therapy.
The value of being conservative
To begin with, all surgery isn`t the same surgery. Years ago, actually decades, gingivectomy was the standard surgical procedure to eliminate pockets. Simply cut away the gum tissue and the pockets were gone. That`s considered ancient history to periodontists today.
Now surgery includes several different procedures and is done for many different reasons and for many different outcomes. If calculus cannot be reached without surgery, then conservative surgical procedures can remedy the situation. Other surgical procedures may be indicated when pocket depth and bleeding are not evident, such as crown lengthening, tissue grafting for greater attached gingiva, or bone regeneration procedures, to name a few.
Good periodontists today recognize the value of conservative therapy prior to surgery. They often wait, as confirmed by research, nine months to a year following debridement therapy and site-specific follow-up before deciding on surgery to provide access for calculus removal.
Antibiotics are used, but they are not routinely dispensed immediately following debridement therapy without adequate evaluation of treatment results, as was done in this study. Both medical and dental specialists caution against the unnecessary use of antibiotics. These drugs should be reserved for specific infections which do not respond to mechanical therapy. Overuse can also lead to antibiotic resistance.
Considering all the facts, this research study did not compare oral antibiotics to traditional periodontal therapy. The protocol was so complex that simple conclusions cannot be drawn.
Generically categorizing all periodontal surgery into one group and glossing over the actual study design oversimplifies and misinforms the public. As dental hygienists, patients ask us about stories in newspapers and magazines, but why is it they always believe the lay press over us? It is up to us to answer their questions and fill in the gaps. If our thinking and treatment is science based, we will be prepared to deal with misinformation from the lay press.
Trisha E. O`Hehir, RDH, is a senior consulting editor of RDH. She also is editor of Perio Reports, a newsletter for dental professionals that addresses periodontics.