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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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