The author responds: Dr. Robert Schoor addresses Bill Landers' differing viewpoint

Dec. 8, 2011
Dr. Robert Schoor responds to Bill Landers’ letter and hopes to influence Landers’ thoughts on the bacterial vs. host response etiology of periodontal diseases.

Editor’s note: If you would like to send a letter to the editors, please email Dr. Scott Froum at [email protected] and Dr. Chris Salierno at [email protected]. We welcome responses from our readers.

Dear Editor,

1. I thank the author for agreeing with my statement that systemic antibiotics are often prescribed inappropriately without instructions for their use. (Click here to read Dr. Schoor’s recent article in Surgical-Restorative Resource titled “The role of antibiotics in periodontal diseases.”) However, when appropriately prescribed, proper instructions to the patient are a mandate, and I emphasize, "appropriately prescribed.” Too often in healthy ASA-classified patients, antibiotics are not therapeutic but a supplement with more risk than improved outcomes. The prescriber must have the professional need to fully inform the patient about risk and reward.

2. WHO and the ADA discourage the use of antibiotics when not therapeutic because in addition to bacterial resistance, all antibiotics affect birth control effectiveness, increase risk for vaginitis, gastritis, and ulcerations of the gastrointestinal tract, and may cause patchy skin discolorations in the summer sun. The geriatric population is at high risk for both hospital-based infections and pulmonary pathosis in institutional settings, and there can be fatal outcomes. The pediatric leadership is campaigning against overuse of antibiotics in children and adolescents to combat diagnosed viral infections because the practice increases allergy and bacterial resistance in later life.

3. Mr. Landers’ references to the Powell and Mealey study minimize their conclusions that morbidities, wound healing, and postsurgical infections have comparable occurrences. If so, why ask about therapeutic outcomes with antibiotics when therapeutic outcomes are affected by postoperative sequelae?

4. The author agrees with the more recent ADA directive of 2007 on the use of antibiotics prophylactically when indicated, and this reinforces the author's opinion. The ADA's reduction in clinical indications for the prophylactic administration of antibiotics from 2004 to its more recent directive clearly states that the risk of administration far outweighs the benefits.

5. In classifying patients using the ASA classification, the academic community accepts the thesis that medical consultation is not routinely required prior to therapy, and antibiotic supplementation is administered at the discretion of the clinician on an empirical basis.

6. Bacterial testing is not widely used in 2011 for the following reasons: sampling is difficult with contamination; the bacteria cultured may not be etiologic; laboratory culturing results vary from lab to lab; and prescribed antibiotics based upon laboratory results may reduce nonvirulent bacteria, allowing more virulent forms to influence the progression of diseases. In fact, there are more publications on hosts than on bacteria-affecting host responses. In addition, topical antimicrobials are more preventive than therapeutic for periodontitis because none reaches subgingival areas beyond shallow sulcus depths.

7. In summary, systemic antibiotics have vital therapeutic values in dentistry and in medicine. The evidence on prevention is an entirely different matter. In host-impaired patients, supplemental antibiotics introduced systemically provide improved therapeutic outcomes, particularly when administered against specific susceptible bacteria. Other than extensive literature supporting the use of chlorhexidine, oral rinses aimed at de-germing the oral environment demonstrate no (and I stress no) therapeutic benefits in periodontal treatment. Commercial oral rinses, particularly oxygen-releasing chemicals, are old recommendations unsupported by the scientific community. Long-term use of oxygen rinses can release oxygen radicals that are potentially carcinogenic. When patients practice effective home care with mechanical plaque removal, supplemental oral rinses add little to prevention of periodontal diseases. Used by patients with poor oral hygiene, oral rinses offer flavor and emotional benefit, but minimal, if any, preventive mechanics.

I hope my comments influence Mr. Landers’ thoughts on the bacterial vs. host response etiology on periodontal diseases.

Robert S. Schoor, DDS
New York, N.Y.
[email protected]