The question below was answered by two members of our panel. Please take the time to read both
Dear RDH eVillage,
I have been a hygienist for 32 years. I worked in a periodontal office for four years and have always done scaling and root planing in each of the general practices where I have worked. I have always been able to obtain good results after doing a thorough job. In recent years, a number of different chemotherapeutic products have been introduced, and I have used them all. In my experience, the one that gave the best results (although it was the most difficult to use) was Actisite.
We are currently using Arestin in my office. The representative encourages us to use it right after SRP. I don't necessarily agree with that method. If I use Arestin at all, it is usually after patients have healed from SRP. I reprobe the areas that still have 5-plus mm pockets, then rescale and apply Arestin. Doing it this way, I find that a lot of the initial pockets resolve without it, so it saves the patient money.
Other hygienists in my office do use Arestin at the SRP appointment. But I have not been impressed at all with the results of Arestin. I don't feel that the clinical results we have been getting match the research. What is your opinion on this product, and what is your experience with it?
You bring up a great question and one that I hear often from hygienists: "When and where do I use local antibiotics?" and "Does it work?"
Although, in this situation, we should place a great deal of weight on the evidence-based theory of these products, we must always use our clinical judgment as well.
Here some questions that dig even deeper into this subject:
• Do we have a clear protocol for using locally applied antibiotics (LAAs)?
• At what point in the periodontal therapy sequence should I use local antibiotics?
• At what level of disease is the use of LAAs appropriate and effective?
• What results should I expect?
My advice would be to look first at your office protocol for periodontal therapy and the use of LAAs. Work together as a team to gather available research and peer-reviewed articles pertaining to LAAs. Then come to an agreement among the doctor and hygienists in your practice as to what your protocol will be. Next, stick to it. Determine at what point you begin active periodontal therapy, at what pocket depths you place LAAs, and at what point in the therapy you use LAAs. Set your fees and even talk about what instruments you use and what home-care products you will supply to support your patients' efforts at home. Educate the dental assistants and administrative team on the details of your protocol and the science on which it is based. This will help them support your recommendations and patient questions about periodontal therapy in general.
The next two questions are specific to when and where you should place LAAs. The research on Arestin supports placement at the time of SRP in pockets 5 mm or deeper. This is based on the evidence that the antibiotic may not be able to penetrate existing subgingival biofilm. In that case, it is necessary for the hygienist to perform thorough decontamination of the sulcus to provide an environment in which the LAA can work. The research on Atridox is a bit different regarding the removal of the biofilm and endotoxins.
The question I hear most often is just like yours: "Can I place Arestin at the reevaluation visit after I have seen the initial results?" My response is usually two-fold, and it supports the idea of placing Arestin at the time of SRP.
One, I want to eliminate the periodontal infection as soon as possible, and two, I want to be sure my patient is comfortable and gets the best possible treatment. If I place the antibiotic in all infected 5-plus mm pockets at the time of SRP, then I will have created the best environment for the antibiotic to reduce the bacterial load for 14 to 21 days to increase the chance of new attachment. If I wait until reevaluation, I may need to anesthetize my patient again and do SRP again on the unresponsive sites, especially if these are deep sites. All of these steps could have been eliminated by treating the sites at SRP.
In my opinion, there are a couple of alternatives you may want to consider. You may decide as a team that you are going to treat all 6-plus mm pockets at SRP and leave the 5 mm pockets for evaluation at the follow-up visit. You may also choose to use systemic antibiotics in some cases. I rarely recommend this but I had a patient just yesterday who was a perfect candidate for systemic therapy. She has generalized, advanced periodontal disease. There would have been almost 100 sites that need to be treated with Arestin based on our protocol. Instead, we decided to go the route of systemic antibiotics based on her disease level and other existing medical conditions.
Lastly, does it work? When used according to the evidence-based protocol, yes. You will tend to see more dramatic results in the deeper pockets. For instance, you may see a greater reduction in pocket depth in a 6 mm to 7 mm pocket than you would in a 5 mm pocket. One of the reasons you may not have seen the best results is because you have used the product in a way that was not studied, so your results won't match those achieved in the clinical trial.
Before we can ever recommend a certain treatment to a patient, we must first believe in our heart that it is the best care we can offer. If, as health-care providers, we don't believe that, then we must do more research until we find a reason to believe or find another treatment that we can recommend with complete confidence.
Rachel Wall, RDH, BS, is a hygiene consultant, speaker, and writer as well as an active clinician. As founder of Inspired Hygiene, Rachel works with dental teams across the country to reach an outstanding level of patient care and performance. Inspired Hygiene serves as the preferred hygiene coaching company for The Productive Dentist Academy and also publishes a free monthly e-zine, "High Performance Hygiene." To get your free subscription, sign up at www.InspiredHygiene.com. For more information, you may contact Rachel at [email protected].
Thank you for your well-thought-out question. In my experience working with practices across the United States, Arestin does do what the clinical studies substantiate; i.e., improve probing depth reduction compared to scaling and root planing alone. For your own review, you can access the online Journal of Periodontology at http://www.perio.org and search for published clinical studies using minocycline microspheres. Keep in mind that the FDA approved this product to be placed at the time of periodontal therapy in the affected areas (pockets of 5 mm or greater with bleeding).
Since part of the disease process involves tissue-invasive bacteria, and studies have confirmed the inability of instrumentation to remove all pathogens in infected pockets, the presence of the minocycline in a controlled released vehicle has the added advantage of suppressing those bacteria long after the effects of SRP have waned. As clinicians, we are constantly striving to assist our patients to the next level of health — disease remission, no infection, and no bleeding as well as smooth roots. In some cases, you may need to place Arestin more than once per pocket.
In fact, Dr. Nagelberg suggests placing Arestin up to three times in the affected pockets. I encourage you to expand your clinical experience to include placement of Arestin in infected sites at the time of scaling and root planing. You may find this ultimately saves the patient dollars due to the improved quality of long-term healing.
Kim Miller, RDH, BSDH / JP Institute / Author,
Lecturer, National Presenter / Perio Updates 2007