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Lazy Lit Review- Locally Delivered Antibiotics

Posted Jan 11 2009 5:44pm

This week's installment of Lazy Lit Review is a first for the young New Dentist Blog...a guest contributor! Dr. Tina Beck is a graduate of UCLA School of Dentistry and is currently a perio resident at The University of Texas. Dr. Beck will be sharing important periodontal literature with us on a monthly basis.

The article: Local Anti-Infective Therapy: Pharmacological Agents. A Systematic Review
The journal:Ann Periodontol 2003
The author: Hanes, Purvis
Why we should know it: Locally delivered antibiotics are flourishing in the commercial marketplace. Flip through any dental magazine and you will see a barrage of marketing in regards to these products. The manufacturers lead us to believe that these are the magic bullet we have been looking for in perio treatment. Just how effective are they?

What we need to know:
It has been well established that the primary etiology of periodontal disease is bacterial plaque in susceptible patients. Therefore, the elimination or reduction of bacterial plaque is of critical importance in the treatment of both aggressive and chronic periodontitis. The most effective means of eliminating or reduce the amount of pathogenic bacteria is mechanical instrumentation. Areas which do not respond to initial scaling and root planning may benefit from the use of locally delivered anti-infective therapy.

The advantages of using locally delivered antibiotics include the delivery of a high concentration of antibiotics to a localized area without systemic involvement, prolonged release over time, minimal risk of developing bacterial resistance, elimination of gastrointestinal or other adverse effects related to the use of systemic antibiotics as well as reduced risk of noncompliance with systemic antibiotic regimens.

Several products are currently available for use for local anti-infective therapy. Sustained-release minocycline, doxycycline, chlorhexidine and tetracycline have all been developed for use in subgingival areas that are not responsive to initial therapy. The following chart describes products that are available for use in the United States.

Arestin© Minocycline Microencapsulated spheres

Atridox© Doxycycline Polymer gel

Periochip© Chlorhexidine Gelatin matrix

Actisite© Tetracycline Fiber

The authors found that Arestin significantly improved probing depths when used in combination with scaling and root planing when compared to scaling and root planing alone. However, the clinical significance of these findings may be minimal as the average reduction in probing depth when Arestin was used as an adjunct to initial therapy was 0.5mm in addition to the 1.45mm of reduction achieved by scaling and root planing alone.

Hanes & Purivs concluded that in some patient populations, “anti-infective agents in a sustained-released vehicle alone can reduce probing depths and bleeding on probing equivalent to that achieved with scaling and root planning alone.” However, the American Board of Periodontology consensus committee explains that there is no evidence that the results achieved by the use of locally-delivered anti-infective agents used alone, without subgingival instrumentation to remove calculus, can be maintained for longer than 12 months.

The committee recommends using sustained-release locally delivered antibiotics in patients who SCRP alone does not achieve the ‘desired outcome’ or patients who have risk factors that are difficult to reduce or eliminate such as smoking or diabetes. Also, the use of these agents is recommended in areas that have increased susceptibility for progression such as furcations that cannot be successfully treated surgically.

Personally, I recommend using any of the above agents (I prefer Arestin©) in patients who have refractory pockets ≤5mm that exhibit bleeding on probing who have successfully completed initial therapy and periodontal surgery, if indicated. Other conditions in which I might consider using these agents is in patients who have systemic contraindications to surgery, in order to avoid performing surgery in the anterior region when only one or two sites are involved, in ungraftable furcations, or around nonmobile implants exhibiting symptoms of peri-implantitis.

As a final remark, I would like to reiterate that the use of locally-delivered sustained-release antibiotics should NOT be used without mechanical instrumentation to remove subgingival plaque and calculus and that this therapy is not a replacement for periodontal surgery as only a maximum of 2mm probing depth reduction can be achieved in ideal cases (when used in combination with scaling and root planing) and should not be expected in all cases.

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