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Endo tips    Better Endo    Endo abstracts    Endo discussions

  Arestin

The opinions within this web page are not ours. Authors have been credited
for the individual posts where they are. - Periotherapist group


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
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