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Systemic Antibiotics in Periodontitis
From: "Stephen Millar"
To: "Periotherapist group"
Sent: Thursday, March 22, 2007 10:09 PM
Subject: [periotherapist] Systemic Antibiotics in Periodontitis
In response to Dr. Loesche's comment:
<<2. The myth of antibiotic resistant bacteria. This is perhaps the
most widely cited objection to the use of antibiotics in periodontal
disease. Yet after years of publicity, no one to my knowledge has
shown an increase in antibiotic resistant bacteria in the clinical
setting, especially to metronidazole.>>
Maybe not so far amongst periodontal bacteria. But if the antibiotic
is administered systemically, what about the risk of generating
metronidazole resistant gram-negative bacteria elsewhere in the
body? Specifically, metronidazole resistant Heliobacter pylori, a
well documented etiological agent in stomach cancer.
Two references to this.
1) From a UK Parliament report:
Memorandum by the Association of Clinical Oral Microbiologists
........Considerable use of the antibiotic metronidazole is made in
the treatment of periodontal disease and this probably accounts for
the reason why dental prescriptions of metronidazole represent the
largest number of prescriptions for this antibiotic in the community.
The widespread use of metronidazole may have contributed to the
increased burden of metronidazole resistance in Helicobacter pylori,
a well documented aetiological agent in stomach cancer.”
2. Source: http://www.upwardquest.com/guided.html
“St. Louis, April 13 -- Scientists in Halifax, Nova Scotia, and St.
Louis, Mo., have discovered why the bacteria Helicobacter pylori,
which causes peptic ulcer disease, is sensitive to metronidazole, a
critical component of the leading H. pylori therapy. They also have
determined how the bacteria becomes resistant to this drug. H. pylori
infects more than half the world's people and is a major early risk
factor for stomach cancer.
The researchers' findings also raise concern about a possible link
between the drug and stomach cancer in people infected with H.
pylori. "The real danger lurks when a person takes metronidazole
without the complete complement of drugs that eradicate this
bacterium," says Paul S. Hoffman, Ph.D., professor of microbiology
and immunology and medicine at Dalhousie University Medical School in
Halifax. "When metronidazole is taken alone, it can be activated by
one of the bacterium's enzymes to produce hydroxylamine, a mutagen
and cancer-causing chemical."
Goodwin A, Kersulyte D, Sisson G, Veldhuyzen van Zanten SJO, Berg DE,
Hoffman PS. Metronidazole resistance in Helicobacter pylori is due to
null mutations in a gene (rdxA) that encodes an oxygen-insensitive
NADP nitroreductase. Molecular Microbiology, 28(2), April 14, 1998.
- Stephen Millar
Some thoughts from Dr. Loesche about systemic antibiotics. . .
Begin forwarded message:
> From: Walter Loesche
> Date: March 21, 2007 10:51:30 AM EDT
> Subject: antibiotics in moderate/severe infections
> I don't know. My guess is that is goes against two powerful
> myths and the failure of dental and dental hygiene schools to
> educate their students.
> The myths are
> `1. The myth of the macho dentist. The few periodontists that i
> have talked to about this issue, assure me that they can obtain the
> desired result simple by scaling and root planing. Their skills are
> such that they do not need any additional help. Many hygienists
> also subscribe to this line of thinking. But we have shown in 4
> studies that metronidazole plus S&RP is statistically better than
> Placebp plus S&RP, the standard of care. Our data indicated that
> it may be unethical to deny patients the benefits of antimicrobial
> therapy, especially in the light of the American Academy of
> Periodontology (AAP) defining periodontal disease as "serious
> 2. The myth of antibiotic resistant bacteria. This is perhaps the
> most widely cited objection to the use of antibiotics in
> periodontal disease. Yet after years of publicity, no one to my
> knowledge has shown an increase in antibiotic resistant bacteria in
> the clinical setting, especially to metronidazole.
> The dental schools and hygiene schools do not teach
> students to use antibiotics to treat periodontal disease. In fact
> just the opposite. Don't use them.
> The AAP has indicated in its guidelines that antibiotics
> are not needed.
> This provides a strong legal disincentive to use antibiotics, if
> the "authorities" in the field discourage their use.
> In regard to the amox/metro combo, there is no scientific
> evidence, ie. double blind, random assignment studies to support
> this usage. In most, if not all instances, metronidazole alone
> would do the job. So another myth is being perpetrated, that of
> shot-gun antibiotic therapy.
>> Dr. Loesche, Why won't the periodontal community accept systemic
>> antibiotics for moderate/severe infections? They are now in
>> agreement about using amox/metro for aggressive or refractory
>> cases but they don't buy it for chronic perio? Thanks in advance,
I understand that suboptimal dosing or when penetration of the agent
is restricted which is the case in smokers. In smokers, Azithromycin
is recommended. When suboptimal dosing occurs, either because of poor
patient compliance or inadequate compliance, the spread of antibiotic
resistant clones becomes a problem. Lynne
Regarding Dr. Loesche's recent comments about antibiotic use that Lynne
re-posted, WL cited his own studies in which the use of antibiotics in
studies demonstrated improved clinical outcomes (on average). This is
accurate. The problem is that the studies reported average results... and
average results include many circumstances in which the antibiotics were
non-contributory. In otherwords, mechanical therapy often works quite well
by itself; other times not. And at sites where it didn't work, was the
problem really inadeq. access? My guess is the answer to this is usually
yes, at least in all but a very small minority of sites/patients.
Later in the same message, Dr. Loesche took the time to "dis" the mix of
amoxi and metro as an antibiotic "shotgun" approach. By his own petard he
hangs, insofar as his recommendation of generalized use of metro amounts to
a single-barreled rhetorical shotgun! (This is because metro can be
helpful, but it's not always needed to achieve clinical health.)
Systemic antibiotics for chronic periodontitis ought to be kept in reserve
when patients don't respond well to top-notch mechanical therapy. The
overuse of systemic antibiotics is why modern medicine has major problems
with antibiotic resistance.
(LAA's can be used any time because of their limited systemic downside, but
they ain't free -- and they may disguise un-addressed etiologies at the site
of interest.) - Mike Rethman
I don't agree with you when you say that systemic antibiotics should
be reserved when patients don't respond to top notch mechanical
therapy. In cases of severe and aggressive perio, the literature
supports its use in combination with SRP. Lynne
How do you measure "The degree of infection?" - Bob
Bob - see the "September 2006 JOP - Diagnosis of Periodontal Disease in
Private Practice" for documentation of usage of phase contrast microscopy
and WBC (white blood cell) counts to diagnose periodontal infections.
This is a simple "quick and dirty" assessment of "degree of periodontal
infection". It is highly effective and efficient for chairside assessment
in clinical periodontal care.
Also, in agreement with Dr. Loesche, the metronidazole alone provides more
than adequate coverage for anaerobic infections and does not cause
antibiotic resistance as far as is known in the literature.
The AAP is unaccepting of antibiotic treatment for moderate periodontitis
because this treatment eliminates anaerobic infections and prevents the need
for more invasive and labor intensive periodontal surgery - thus it is very
affordable treatment for patients. I will never look back - David Apsey
> I would love for this opinion about Walter Loesche to be spread
> 'round the world. He does his "due dilligence" and he pushes the
> envelope. His approaches are reasonable, minmally invasive and
> when combined with the technology we have today, especially
> endoscopic debridement, we are looking, literally "looking" at the
> future of periodontal therapy. I am not saying that surgical
> treatments are not valid or not necessary. I am saying that there
> can be far more definitive treatment done with visual "cleaning"
> and systemic and/or local antibiotic "disinfection" then ever
> before. I still do my share of surgery but not much for
> periodontal disease, more for pre-prosthetic, mucogingival and most
> of all implant treatment - John Kwan
I agree entirely with John Kwan in his statement, "I still do my share of
surgery but not much for
>periodontal disease, more for pre-prosthetic, mucogingival and most of all
I'm also in this camp and I do advocate mucogingival or preprosthetic and
implant surgery where necessary. Also, certain "atraumatic" surgical
extraction techniques that are designed to preserve alveolar bone are in the
same category of "periodontal" surgery. Contrarily, gingivectomy and flap
procedures to "gain access" to the pocket or for "pocket reduction" really
need to come to an end.
We can all benefit from the discussion and optimization of conservative
procedures which can replace these surgeries in clinical periodontal care
over time. - David Apsey
David Apsey wrote: "...gingivectomy and flap
procedures to "gain access" to the pocket or for "pocket reduction" really
need to come to an end...."
M.Rethman responds: David: Please explain your opinion.... No one
disagrees that access surgery isn't needed if access and resolution of
infection can be gained via other ways mechanical. In the your same vein,
one could argue that perioscopy or even ScRP doesn't need to be done because
you imply that something else works as well or better than debridement.
The real question boils down to when one doesn't get the etiology of a
lesion as a site obviated, what should one do? You apparently think...
"well, do everything you can there and elsewhere, including repeated efforts
using systemic antibiotics (and LAAs too, probably) but never periodontal
surgery." Why? What's so magical about this clinical frontier... other
than its true-believer-type religiosity? Or is it that somewhere, somehow
someone may actually need to refer to a peridontist who is a member of what
you seem to think is an information-suppressing,
Yes, I am trying to pin you down regarding your tendency to offer-up
Some thoughts on Dr. Loesche's thoughts.
From my own experience, I'd have to agree with Dr. Loesche. The 'myths' he
listed are still widely held among dentists and hygienists.
These myths are compounding by human psychology, namely the near universal
human impulse to resist change. Some psychologists maintain that our
suspicion of innovation is based on fear of loss.
* Loss of control
* Excess uncertainty
* Surprise & shock
* Being "different"
* Loss of face
* Concern about future competence
Others believe that it's an ancient genetic trait. Most organisms thrive in
a homeostatic environment. Change threatens survival. Behaviors that
minimize change are thus favored.