Site-specific therapies

Dear Dianne,

Recently, I attended a seminar at one of the large meetings. The speaker talked about various site-specific therapies for treating periodontal disease. It was very interesting, and, as I listened, I felt this would be a good adjunct to add for patients undergoing periodontal therapy.

When I went back to work and told my doctor about what I’d learned, he said he did not have any confidence that site-specific therapies would do any good. Further, he expressed reluctance to even try the product.

Most of the patients in our practice have some type of dental insurance. I think the real reason behind my doctor’s reluctance is his belief that dental insurance will not pay for therapies like this.

What has been your experience with site-specific therapies? How can I show my doctor that this would be a good thing for some of our periodontally difficult patients?

Not Giving Up in Nevada

Dear Not,

The first problem I see is that your doctor did not go to this course with you and hear the information that was presented. He is simply not “on board” with current information. There are various site-specific products for treating periodontal pockets. Two products, Arestin® and Atridox®, are antibiotic in nature. A third product, PerioChip®, is actually a 2.5 mg chlorhexidine disk that is inserted subgingivally into a pocket.

Atridox is a 10 percent doxycycline gel by CollaGenex. It is mixed at the time of usage and placed in the pocket by a syringe with a small canula. It hardens very quickly and stays in the pocket for seven days, delivering an antibiotic punch to susceptible bacterial species that reside there. A German study that was published in the January 2005 Journal of Periodontology found these conclusions: “The addition of subgingival instillation of a 14 percent doxycycline gel resulted in pronounced reduction of periodontal pathogens after three months, and stabilizing results up to six months after therapy. Resistance to doxycycline was not induced.”

Arestin is a 1 mg minocycline powder that requires no mixing. It comes premeasured in plastic tips that are inserted into a syringe. The material is expressed into the pocket, where it hardens and stays anywhere from 23 to 28 days. According to the manufacturer, OraPharma, it delivers a full antibiotic punch for 14 days. After that, the efficacy begins to drop off gradually until the product hydrolyzes completely.

A study published in the Journal of Periodontology comments: “A recent Phase 3 trial demonstrated that adjunctive treatment with minocycline microspheres resulted in significant reductions in patient mean probing depths as compared to scaling and root planing (SRP) alone. The objective of the present study was to evaluate clinical relevance of these changes within the trial, using proposed site-based criteria.” Conclusions: “This secondary analysis indicates that treatment with SRP plus minocycline microspheres is consistently more effective than SRP alone in providing clinically relevant site-based responses in patients with chronic periodontitis.” (J Periodontol 2004;75:531-536 )

These are just two studies. There are many more archived on the AAP Web site (www.perio.org). As you can see, there are studies that support using site-specific antibiotic therapy in the treatment of periodontal disease.

The third product I mentioned, PerioChip, also has some good research supporting its use. A study published in the Journal of Periodontology examined whether “subgingival administration of chlorhexidine gelatin bioresorbable chips enhances bone gain when used in conjunction with guided tissue regeneration.” The conclusion: “These pilot results indicate that locally delivered, controlled-release antimicrobial treatment may improve the amount of bone gain during guided tissue regeneration procedures. These data support the evidence that infection control is an important variable in successful regeneration.” (J Periodontol 2003;74:411-419)

Since this product is not an antibiotic, its use may be preferred in some situations when bacterial resistance or antibiotic allergy is an issue.

However, when you talk with wet-fingered clinicians, results vary. One reason could be that, although Socransky and his group have identified the top three periodontal pathogens (the “red group”), there are more than 500 different species of microbiota that have been cultured from the mouths of people with periodontal disease. We do not even have names for over half of the species that have been identified. Further, viruses, yeasts, and fungi have also been associated with periodontal disease.

The point is: We do not have a magic bullet. What works great with one patient may not work well with another. However, this information should not deter us from using products that have been shown, both in clinical practice and in controlled studies, to help some periodontal patients get better.

It has been known for years that systemic antibiotics often help people with periodontal disease achieve better clinical outcomes, especially diabetic patients. However, an advantage of a site-specific therapy is that the whole body doesn’t have to be flooded with antibiotics. The clinician can treat just the area with active infection.

Another point worth mentioning is that pocket depth reduction, while desirable, may not be the goal. The goal may be to stop the progression of the disease. If your patient has sites that have not responded well to scaling/root planing, a site-specific therapy could be of great benefit.

One thing to remember about site-specific therapies is that the fee should reflect the amount used. Since Arestin is premeasured and one tip will treat one site (not one tooth if there are numerous sites on the same tooth), the fee could differ from tooth to tooth. For example, let’s say on tooth No. 3, the pockets were 6 mm on the distofacial, 3 mm facial, and 6 mm mesiofacial. The lingual readings were normal. You would need to use two tips, one for the distal pocket and one for the mesial. Let’s say that tooth No. 4 has a 6 mm reading on the distofacial and all the other readings are normal. So No. 4 would only need one tip. The fee for tooth No. 3 would be higher than the fee for tooth No. 4.

Another good indication for using D4342 (see sidebar about insurance codes) is when a new patient comes through the hygiene department first. The patient may be expecting to get his teeth “cleaned,” but you determine he has periodontal disease. The best thing you can do is say to the patient, “Mr. Jones, from what I see in your mouth and from the X-rays we took, there seems to be some problems with your gums and the bone around your teeth. Before I proceed any further, I need the doctor to come in and have a look.”

Then you inform the doctor (out of the patient’s hearing) of the situation. The doctor comes in, meets the patient, does some initial probing, and says, “Mr. Jones, from what I see in your mouth and on these X-rays, you have periodontal disease. This is a chronic infection in your gums. If it is not treated right, it will continue to erode the bone around your teeth. The good news is that we have good success treating this and stopping the disease.”

By this time, you may only have 20 to 30 minutes left. So, instead of sending the patient away with no scaling, I suggest you start a quadrant and use the D4342 code.

It is my hope that when you present your doctor with some good evidence that these treatments really do help some patients, he will be more amenable to trying them.

Best wishes,
Dianne

Dianne D. Glasscoe, RDH, BS, is a professional speaker, writer, and consultant to dental practices across the United States. She is CEO of Professional Dental Management, based in Frederick, Md. To contact Glasscoe for speaking or consulting, call (301) 874-5240 or email [email protected]. Visit her Web site at www.pro fessionaldentalmgmt.com.