Lynn asks: Diane, do you use  Arestin and under what conditions do you use it? Also, did your periodontal practice prescribe systemic
antibiotics and under what conditions did you prescribe them?
Diane: Yes, I do you Arestin. I mentioned before how I was trying to cram tetracycline into pockets per research before we really had appropriate
products. When performing conservative periodontal therapy, I place Arestin in any sites greater than or equal to 6mm that also either bleed or
have purulent exudate. In my experience, more shallow sites usually resolve anyway. When I have supportive periodontal therapy clients, I offer
Arestin as an adjunct to therapy if there are sites that are 6mm or greater. If these sites persist, I offer perioscopy or the periodontist.
I used to have my own phase contrast/dark field microscope to aide in determining microbial activity and suseptibility. I miss that. Thinking of
buying a new one.

About the antibiotic therapy. I used to do that more routinely. But now with Arestin, I have a hard time justifying subjecting the whole body to
a barrage of antibiotics to get a pittance dose in the crevicular fluid, when I can get a good dose right there where we need it without all the
side effects. Last year, John may remember, I had one baffling case who showed up with generalized 2mm pd increases all over his mouth and
something like 28 purulent sites compared to previous years of pretty healthy periocharts. We started off very conservatively, because we did not
know what was going on. His med his was clear, no change in life stresses, or lifestyle. Just cavitroned, hand scale, cavitron, OHI with PerioAide,
WaterPik, Sonicare (too many sites for Arestin). Two months later, same. Consulted with Roger Staumbaugh and John Kwan. Both agreed on blood
testing, CRP, diabetes, etc., etc. followed with therapy and systemic antibiotics. Blood tests all normal. Put him on a com Hope this answers your
question. Oh, Mike, he refused to go to the periodontist and wanted to try anything else first.
I have a question. Since Arestin is minocycline, and minocycline is in the tetracycline family, does it act the same way in calling forth fibrin
from the blood supply in the connective tissue as studies have shown that tetracycline does? When I asked Dr. Bill Killoy this, he indicated to me
that it does. What is your opinion and/or better yet, can anyone site any studies out there on this? - Diane
Ooop! I'm sorry. That was a combo of Metrinidizole and Amoxicillin. Not Ampicillin.
- Diane
Fantastic therapy, Diane! You are right on. . . . . . all that you have posted is supported by SCIENCE and especially Socransky's work on
periodontal pathogens.- Lynn 
From: Jane
To: periotherapist groups
Sent: Thursday, August 10, 2006 4:37 PM
Subject: [periotherapist] About Arestin and Peridex or Chlorhexidine

I have been asked whether or not it is beneficial to use Peridex or Chlorhexidine prior to placement of Arestin and wondered what this group thought
of this process.
I had asked someone with Arestin about it and she told me that to the best of her knowledge there is no adverse reaction between the two but why use
both to kill the same bacteria? I totally agree but would like to hear the groups'  feelings on this as well..especially you, Mike , and Dr. Keyes.
Thanks in advance. Jane Weiner, RDH FL

Jane, I will irrigate the entire mouth with .2% CHX not Peridex which is over-diluted to a .12% solution. The Arestin, I will place after irrigating
in the needed pockets. SandySheffler RDH
From: Bill Landers
To: periotherapist groups
Sent: Friday, August 11, 2006 11:09 PM
Subject: RE: [periotherapist] About Arestin and Peridex or Chlorhexidine

Jane asked: "Is it beneficial to use Peridex or Chlorhexidine prior to placement of Arestin?"

I have no data, but some interesting questions come to mind that would influence the answer:

1. Is Arestin is universally bactericidal against ALL periodontal pathogens?
2. Is it effective 100% of the time?
3. Does the active agent diffuse to all parts of the pocket in high enough concentrations to be effective at any distance from placement?
4. If efficacy independent of placement technique? I.E. Does placement technique affect results?

If the answer is 'yes' to these questions, there would be no additive benefit to irrigating with CHX beforehand.

If the answer is unknown or "no", then there might be some benefit to a prior irrigation.

1. CHX irrigation 'could' reduce the number of bacteria present before placement, potentially increasing the potency of Arestin. (Arestin
releases a finite # of molecules per time. If there are few bacteria for those molecules to bind with, the dose is effectively higher, unless the
amount released is sufficiently large that it completely overwhelms any conceivable # of bacteria that might be present.)

Some other considerations:

1. How much CHX would remain post irrigation?
a. Crevicular fluid flow would flush most agents from the pocket in 5-15 minutes.
b. CHX, however, is substantive. Some portion would remain bound in the pocket.
c. Is there bleeding? Blood binds and inactivates CHX, reducing efficacy.

2. So, some residual CHX might be present for some time after placement, but probably not for very long. If I recall correctly, the longest CHX has
been shown to be present after a single application is on the order of 20+ hours or so. Crevicular flow probably continues to reduce the effective
concentration of any residual active CHX over that time.

3. Conversely, Arestin is continually releasing active agent over time. It's likely, therefore, that its concentration in the pocket would quickly
overwhelm the residual effects of a single prior irrigation with CHX.

4. Also, the modes of action are different, but that doesn't necessarily rule out chemical interactions. If present, such reactions could:
a. Have no direct effect
b. Inactivate the efficacy of one or the other ... Or both.
c. Potentiate one or both.

Hope that complicates things. :-) - Bill Landers, President, OraTec

Thanks Bill and others who have commented on the use of both these products at the same visit....
I too agree that it is nice to flush out the sulcus with DHX prior to treatment to lower the number and strength of the pathogens in the sulcus and oral
cavity ( with a rinse as well ) but as Bill queried....is the efficacy of either product effected if both are used or CHX prior to placement of Arestin???
But at least it does give us some food for thought,eh? Again, thanks.- Jane Weiner, RDH, FL

Re: "Jane, you also need to know that, according to the systematic reviews of the literature on Chx as a professional irrigant, when used in
conjunction with SRP, the Chx does not offer any additional benefit. This data comes from the Annals of Periodontology, 2003 and I have a
copy of it at home. I irrigate after SRP because I like flush out the pocket and try to prevent a periodontal abscess but this is an
anecdotal suggestion that is not backed by science." - Lynne H. Slim, RDH, MS

Mike Rethman comments: Although Lynne cites this correctly, it's important  to remember to keep this and similar recommendations in context in light
of the fact that the studies used to make this conclusion used avearged data. And, as I've pointed out here repeatedly, the use of mean data can be
problematical insofar as occasional but genuinely positive results can get diluted so much that they go undetected statistically. Therefore, one
ought to consider looking at the detriments to using Chx this way (none that I know of other than the cost of a cheap material and the time it takes
to use it) versus the (small) possibility that it may be beneficial. Based on that, I'd use it. However, PLEASE don't hang your hat on a belief that
Chx is helpful on a consistent (or perhaps even singular basis) -- like too often happens regarding other treatment protocols that get enthusiastically
adopted so as to avoid referrals, for example. - Mike Rethman

I don't understand your post, Mike. Are you saying that the systematic reviews aren't meaningful? So if the some of the
systematic reviews are problematic, what are we supposed to be using? The AAP decided in '03 that some local antimicrobials were useful in
slowing down the inevitable formation of new biofilms and now the AAP seems to be redefining its use. Who are dental professionals supposed
to believe? Tom Rams tells me that Chx does not provide adjunctive benefits as a subgingival irrigant but that povidine iodine does and
the AAP tells me that Chx is not a good choice, either so, again I say, who are we supposed to believe? Oh. . . . and I forgot, Slots
also tells me that Chx is not useful and Socransky likes Arestin. I could go on and on. . . . . . . I dunno who I believe. I use citrus
listerine in my water bottle and I'll stick with that because it tastes good!! I like Arestin and would use more if it wasn't so
expensive and we do have to weigh cost/versus benefit for our patients. Lynne

P.S. BTW, John Kwan, Periodontist places most of his patients on a short three course of Azithromycin and uses the endoscope. He uses
Arestin, too, but not on every patient and in every pocket. Sam Lowe or is it Low from Florida likes povidine iodine as a professionally
delivered irrigant, also. McDevitt in Atlanta gets very good results  from endoscope-assisted nonsurgical periodontal therapy and uses
Arestin occasionally in deep pockets under certain circumstances. No- one I know is using Chx routinely for professional irrigation because
it is expensive. - Lynne
Hi Lynne, the answer to your question is in my previous post. I expanded it here:

"...Therefore, one ought to consider looking at the detriments to using Chx this way (none that I
know of other than the cost of a cheap material and the time it takes to use it) versus the possibility that it may be beneficial at a
particualr site. Based on that thinking, namely that it''s cheap, harmless and its use sorta makes a least a little sense, I'd use it."

Yet I strongly caution colleagues to not put much faith in the hypothesis that Chx does much if anything when used as an irrigant along with ScRP.
(Sorta reminds me of the much more expensive (time and money) microscopy...) But because Chx is cheap (in cost and time) and easy to use and it is
notionally attractive, why not? If you don't think it cheap, well that's a "horse of another color" -- don't use it.

I am NOT saying that systematic reviews are not meaningful. Rather that they, like the studies on which they are based, have interpretive
limitations that are limiting when it comes to real-life situations. I was quite pleased to write on some of the limitations of systemic reviews in the
AAP paper published in JADA reporting the condensed version of what you are reading in the '03 Annals.

On a related issue, you seem stuck on what you see as an inconsistency between the systemic review that discussed Arestin-like materials v. the new
AAP statement. I don't see why. Please drill down and get to specifics. I see the latest AAP statement as a caution to practitioners that just because
a therapy shows statistically significant benefits, the real-life benefits may be small (assuming the average response) and may have little
meaningfulness in terms of the cost (cost includes $$ cost, time, opportunity cost v. pursuing an alternate course) etc. I've already
explained where I have (minor) problems with this thinking... indeed it's the same argument I'm using with regard to Chx + ScRP. However, in the case
of LDAs, it's a legit mega-concern that these are being used as if they are panaceas... expensive panaceas that get used at the expense of lost time,
disappointed (of uninformed) patients and, in many cases I suspect, the continued progression of periodontitis. I don't think that similar
over/misuse of Chx as a panacea is as likely, at least now anyhow. The new AAP statement attempts to outline reasonable guidelines for the use of LDAs.
These AAP guidelines are not perfect or absolute.

Next time you talk to Slots or whoever, pose the question: "Jorgen, you told me that Chx is "not useful." By this do you mean never useful? If so,
how do you now this? He'll have no rationale answer but: "Well, it may be, sometimes... but we have no proof." And you will leave, rightly thinking,
that Chx may indeed be useful, sometimes.

However if Chx seems too expensive, as you wrote, then don't use it on that basis. BTW, it's Sam Low, pronounced "Lau".

Regarding the fact that Soncransky "likes Arestin", well the real question is for what? I like Arestin -- indeed I did some of the early research on
their polymeric microspheres in the late 1980s. But if you are looking for a universally applicable solution for every periodontal pocket, sorry, none
exists.

Aren't chronic diseases fun? - Mike Rethman
Entertaining post, Mike. I'll mull these thoughts over and get back to the group. Lynne 

The doctor I work with has asked me the folllowing about Arestin and I did my best to answer it with visuals in hand. He asked me to also pose the
question to you for response:

"I question the practice of placing 2-3 doses of Arestin in and around a single rooted tooth with or without pocket communication from mesial to distal.
I visualize the bacteriocidal effect permeating beyond just the immediate pocket area where it is placed making multiple doses unnecessary. Does the
bacteriocidal affect permeate around the root of a periodontally involved tooth with or withouy communication between the mesial and distal pockets?
Are 2 doses of Arestin necessary?" - Diane