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When to apply local antimicrobials

From: Lynne H. Slim To: periotherapist group Sent: Tuesday, August 02, 2005 7:40 AM Subject: [periotherapist] 4381 local antimicrobials Are there any guidelines, based on systematic research consensus, on WHEN to apply local antimicrobials. . . . during initial therapy or at re-eval? Considering the cost of these products, has the AAP studied this issue in order to assist clinicians who want to do is right based on the evidence to date? I recently talked to the Dept Head at NYU School of Dentistry who told me that his perio students now apply local antimicrobials during initial therapy for those adults with localized periodontitis. It makes sense to me to apply these medicaments at the time of initial chemo-mechanical debridement but many clinicians wait until re-eval to re-disenfect with local antimicrobials. If it weren't so expensive, I am certain that almost all clinicians would apply it during initial therapy - Lynne Hollister Slim, RDH, BSDH, MSDH Considering the serious pathogens that may be involved and the bacteremias that always occur with instrumentation of the gingival tissues, an antiseptic should always be used when treating periodontal lesions, minor or severe. Many inexpensive agents are available. For example: betadine (OTC), chloramine-T (old fashioned but good), chlorhexideine (concentrate can be purchased and diluted), Therasol (from OraTec), weak Clorox (1 teaspoon per pint water). I always irrigated lesions carefully before, during, and after instrumentation. This is the essence of chemo-mechanical therapy. For some very good information on this subject I can recommend the OraTec catalog, which you can obtain at 800-368-3529 - Paul Keyes Thanks for the post, Dr. Keyes. It certainly can't do any harm but we all need to keep in mind that the biofilms are a really persistent and new concern for those of us who are following the biofilm research. Dr. Keyes, if you can, go to the Montana Biofilm research center online and try to find the 3-D dimensional example of what happens to biofilm when it is hit with antibiotics. It's really nifty. I'll try to find the link for you. Hold on. - Lynne It was my take that Lynne was asking about sustained slow release biodegradable antimicrobial site-specific drugs like Arestin, PerioChip and Atridox, however Paul's suggestions are good ones in terms of disinfecting sites before during and after SRP. Paul's suggestions are probably effective at reducing bacteremia (if not in frequency, at least in degree), should cut aerosolization of some pretty mean bugs and, also important, these techniques are cheap and at the very worst are harmless. And for me, it's nice to be able to agree with Paul (for a change)! - Rethman . . I value both of their opinions and know that their positions are based on many years of practice and research. The biggest problem for me in making decisions about antiseptics and antibiotics is the cost issue. I'd love to bombard all of the pockets with a time-released local antimicrobial but I am still looking for a consensus/guidelines on placement. John Kwan likes Arestin (he's a great practicing periodontist in California) and routinely places it during initial therapy. . . and he also uses povidine iodine as an antiseptic, too, as an irrigant. . . and another practicing periodontist that I love and adore named Mike McDevitt sometimes applies Arestin during initial therapy depending on the diagnosis. Both Kwan and McDevitt use perioscopy. In patients with aggressive periodontitis, the hygienists who work with (not for) McDevitt pull out all the stops and apply Arestin and then even pack the quads afterwards. Would love to survey different clinicians to see what each one is doing and why - Lynn H Slim Wanted to follow up on this thread. I can understand the benefit(s) of irrigating with an antiseptic after SRP and even before the placement of a locally-applied antimicrobial in localized periodontitis, but what value is there in irrigating before initiating debridement? Sure, I understand that the bacteria get into the bloodstream but we don't yet have the science to know what happens to the little critters. The DNA for anaerobes does show up in the arteries (according to one study I read) and one particular scientist has found evidence of certain anaerobes in the arteries but we don't yet have a definitive answer to this question. Once the bacteria enter the bloodstream, it's quite possible that they are engulfed and destroyed. I agree that it is important to pre-rinse before any hygiene procedure, which I do routinely, but I don't know that there is any consensus on pre-irrigation before debridement. What's your take on this, Dr. Keyes, and is it based on today's accumulated science? Am interested in your comments. We do understand that there is an accumulation of evidence that periodontal disease may be a risk factor in cardiovascular disease and stroke. The most compelling evidence is found in an NIDCR-supported study called Oral Infections and Vascular Disease Epidemiology Study (INVEST). In this study of 1056 older adults, the presence of peridontopathic bacteria in dental plaque was associated with an increased thickness of the carotid artery wall. This association was found even after adjustments were made for other conventional risk factors like SMOKING, ETC. We all recognize that SMOKING is a variable that needs to be controlled because it, by itself, is a significant risk factor for both periodontal disease and cardiovascular disease and stroke. Based on everything I've read, I cannot see any reason to irrigate BEFORE debridement. One important theraputic outcome is microbial load reduction and chemomechanical debridement accomplishes this important task. Anyone agree/disagree? - Lynn H Slim I'm not a huge fan of irrigation because like many adjuncts some folks tend to give it more value than they ought, however I've seen ABSOLUTELY NO evidence over the years that suggests it's a bad thing and some evidence that suggest it's helpful. Notionally, IF irrigation helps therpeutically at all, and it probably does at least a little doing it twice seems better than once. However with regard to decreasing the bacterial load introduced into the bloodstream, decreasing loosely associated plaque (LAP) bacterial counts before mechanical therapy likely decreases the amount of bacteria introduced into the bloodstream by instrumentation... and the LAP bugs are considered by many to be the worst buggers of the bunch. And, anything that may help mitigate any sort of aerosolization of these bugs seems attractive to me.... Finally, because it costs so little (time mostly -- and I know that this is a hurdle for many), it seems to me to be a reasonable approach even in light of the limited evidence that exists in its support and the likelihood that it doesn't make much difference (periodontally or cardiovascularly) 99+% of the time. Cost/benefit analyses apply to everything, even when the benefits, if any are poorly understood The biggest danger that I see is that poorly informed therapists may mentally elevate something like irrigation into "panacea status." - Mike Rethman Agree, Mike and it is very important for hygienists and dentists to be aware of the evidence w/ regards local delivery irrigants. BTW, when did we come up with the abbrev. LAP. . . . I can't keep up with all of the terms. . . . biofilms, plaque, planktonic bacteria, etc. It's a bit overwhelming at times!!!!!! Enjoy a macadamia nut for us. . . I am guessing that they are cheaper to buy in Hawaii. Isn't that right? - Lynn H Slim

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