Mark T. Litterer, D.M.D
Aubrey H. Scher, D.M.D.

Non-Surgical Therapy

Antibiotic Therapy

Systemic Antibiotic Therapy

Systemic antibiotics are medications that, when given, affect the whole body. Normally they are administered in pill form when used in periodontal treatment. Periodontists use systemic antibiotics to treat acute infections, such as a gum abscess (gum boil), and also before treatment when patients have certain medical conditions, such as mitral valve prolapse. Systemic antibiotic therapy may also be used following implant surgery, bone graft surgery or regenerative periodontal surgery to reduce the chance of an infection during the early stages of healing and to help improve initial wound healing.

Because periodontal disease is an infection, it would seem logical that antibiotics would eliminate the problem. Unfortunately, when treating routine periodontal breakdown, the effects of antibiotics are short-lived. This is because the bacteria that cause the disease reform immediately after the antibiotics are discontinued. In fact, periodontal cleanings done to remove calculus and plaque appear to be as effective as antibiotics in controlling the infection.

As a rule, for most routine periodontal conditions, systemic antibiotics are not necessary or even useful. In some advanced cases there may be very specific harmful bacteria that can be eliminated with systemic antibiotics. For these cases, a short-term treatment of antibiotics may be useful. In cases where traditional treatment does not produce the expected results, the mouth may be cultured to find out what specific bacteria are present. This will guide the therapist on which antibiotic to use.

Because overuse of systemic antibiotics can cause patient sensitivity and bacterial resistance, they should be used only when specifically indicated.

Low Dose Antibiotics

Recently there has been interest in the use of low dose antibiotics (Periostat). The dose is so low the drug does not act to kill bacteria, but rather to change the way the body responds to infection.

One interesting effect of certain antibiotics is they not only kill the bacteria that may cause periodontal disease, but they also reduce the body's production of collagenase, an enzyme that destroys gum tissues which, amoung others, are made of collagen. We all need some collagenase as older tissue is removed and replaced with new tissue. However, in periodontal disease there seems to be an overproduction of collagenase, causing the body to destroy healthy gum tissue. The antibiotic doxycycline was found to combat these enzymes, even in doses so small that there was not an antibiotic effect. The advantage of the smaller doses is a great reduction in the chance of resistant bacterial strains forming, and in fewer side effects.

Periostat is a capsule of 20mg of doxycycline, and two clinical studies have shown that patients who take 2 capsules daily have a reduction in clinical inflammation. The studies were limited to 9 months, and so there is no official recommendation to take the product for a longer period. From a practical standpoint it seems that Periostat can be taken indefinitely. However, some preliminary work indicates that there is a positive residual effect for 3 months after stopping the drug, and so some practitioners recommend taking Periostat three months on, three months off. The daily 40mg doses are so low that they do not even qualify as an official antibiotic, and there is no known effect on the pocket bacteria. Thus, Periostat must be used in conjunction with other therapies that address bacterial removal. Indications for Periostat are generally seen in recall patients who are not responding well, have generalized inflammation in spite of reasonable oral hygiene or are suffering from a host modulation deficiency.

Local Antibiotic Therapy
PerioChip
Arestin

While systemic antibiotics have a very limited use in treating periodontal disease, there has been much interest in local antibiotic delivery. If an antibiotic can be delivered directly to the pocket, without the patient having to take systemic doses, there are far fewer side effects, and fewer chances of resistant bacteria forming. In addition, with direct local delivery, the concentration of the antibiotic at the diseased site can be 100 times greater than taking the medication orally/systemically. However, it is important to note that all local delivery antibiotics are recommended as adjuncts to scaling and root debridement, and not as stand-alone treatments.

PerioChip
PerioChip is a thin wafer that contains chlorhexidine. While chlorhexidine is not an antibiotic, it is a powerful antiseptic and kills most pathogens. The wafer slides under the edge of the gum into the pocket, a simple procedure that does not require anesthesia. The wafer dissolves over several days, and does not have to be removed.

 

Arestin
The most recent local antibiotic therapy introduced consists of small spheres of minocycline, a derivative of tetracycline. This drug, similar to the ingredients in Actisite and Atridox, is very effective in killing the bacteria that are thought to cause periodontal disease. The primary advantage of this new product is the ease of use. The spheres, which look like a fine powder, are contained in a small blunt plastic canula, and are delivered into the pocket. This requires no anesthesia. The spheres are bioadhesive, and stick to the pocket wall where they slowly release minocycline over a 14-21 day period. Because the spheres are also biodegradable they do not require removal.

 

 

Generally speaking local delivery antibiotics are used in the Periodontal Maintenance phase of therapy, when isolated areas of the mouth seems to be worsening or not responding to conventional therapy. Their use is generally not recommended during the active phase of treatment. The effectiveness of these products is somewhat controversial, and while there is usually some improvement, whether these results are long-term has yet to be determined. Certain cases seems to respond better than others, and we will help advise you whether these treatments may be beneficial in your particular case.



Scaling and Root Planing

Scaling and root planing is the removal of all hard and soft deposits from the teeth. Scaling usually refers to removal of deposits above the gum line, while root planing refers to removal of deposits on the root itself, below the gum line. Deep cleaning is a lay term generally referring to root planing (under the gum). The soft bacterial deposits that form on tooth surfaces will become hard over time, attaching to the root like a barnacle to a boat hull. These deposits must be removed to eliminate the infection in the gum. Complete scaling and root planing is generally done with local anesthetic ("Novacaine"), and takes from 2 to 6 hours, depending on the case. The deeper the pocket the harder it is to remove all deposits, because of difficulty in seeing and reaching deeper deposits. With deep pockets, surgery is the only way to effectively clean the root surfaces.



Oral Hygiene Instructions

Oral bacteria that collects under the margin of the gum is the cause of periodontal disease. It is VITAL that the patient remove this plaque once/twice daily, to prevent reoccurrence of the disease. Oral hygiene and regular maintenance appointments are the critical steps of long term success. No matter how successful the initial treatment, without adequate follow-up care the disease will reoccur. The patient must truly take responsibility for his or her own oral health.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Brushing and flossing are the two main corner stones of oral hygiene. Most people brush, but few have been shown to remove the plaque properly from under the edge of the gum. The bristles of the brush must slide into the cuff of the gum, like a broom may slide under the edge of the door. The brush should be positioned at a 45 degree angle to the tooth, and move in a small circular motion, or shimmy back and forth. Scrubbing is not recommended, in that it may lead to gum recession. We recommend the use of an electric toothbrush and would be happy to discuss which one would be best for you.

 

 

 

 

 

 

 

 

Electric brushes have been shown to be more efficient than manual brushes. For most people they are easier to use. However, they also must be properly placed around the teeth to remove plaque. They do NOT replace the need for floss.

 

 

Sonicare electric brush head

Flossing is the only way to remove plaque from under the gum and between the teeth. Because most periodontal disease starts between the teeth, flossing is even more important than brushing. MOUTHWASHES DO NOT REPLACE THE NEED FOR FLOSSING. Good flossing is a skill that takes practice, but nothing can replace it in preventing periodontal disease. When learned, it should only take 2-3 minutes a day. When flossing it is important to slide the floss slightly under the gum, wrapping around the tooth as far as possible. A clean surface will elicit a "squeaky clean" sound.

 

 

 

 

 

 

There are many other aids that are available to help with oral hygiene. These include small brushes that can clean spaces between the teeth (proxibrush), and threaders to help guide floss under bridges (floss threaders). Toothpicks may be recommended to help clean furcations . Each patient is individually assessed to see what may help optimize their cleaning efforts. Our office will assist you with these special instruments.

 

 

 

 

 

While brushing the outside surfaces of your teeth, position the brush at a 45-degree angle where your gums and teeth meet. Gently move the brush in a circular motion several times using small, gentle strokes. Use light pressure while putting the bristles between the teeth, but not so much pressure that you feel any discomfort.

When you are done cleaning the outside surfaces of all your teeth, follow the same directions while cleaning the inside of the back teeth.

To clean the inside surfaces of the upper and lower front teeth, hold the brush vertically. Make several gentle back-and-forth strokes over each tooth. Don't forget to gently brush the surrounding gum tissue.

Next you will clean the biting surfaces of your teeth. To do this use short, gentle strokes. Change the position of the brush as often as necessary to reach and clean all surfaces. Try to watch yourself in the mirror to make sure you clean each surface. After you are done, rinse vigorously to remove any plaque you might have loosened while brushing.
If you have any pain while brushing or have any questions about how to brush properly, please be sure to call the office.

How to Floss :

Periodontal disease usually appears between the teeth where your toothbrush cannot reach. Flossing is a very effective way to remove plaque from those surfaces. However, it is important to develop the proper technique. The following instructions will help you, but remember it takes time and practice.

Start with a piece of floss (waxed is easier) about 18" long. Lightly wrap most of the floss around the middle finger of one hand. Wrap the rest of the floss around the middle finger of the other hand.

To clean the upper teeth, hold the floss tightly between the thumb and forefinger of each hand. Gently insert the floss tightly between the teeth using a back-and-forth motion. Do not force the floss or try to snap it in to place. Bring the floss to the gumline then curve it into a C-shape against one tooth. Slide it into the space between the gum and the tooth until you feel light resistance. Move the floss up and down on the side of one tooth. Remember there are two tooth surfaces that need to be cleaned in each space. Continue to floss each side of all the upper teeth. Be careful not to cut the gum tissue between the teeth. As the floss becomes soiled, turn from one finger to the other to get a fresh section.
To clean between the bottom teeth, guide the floss using the forefinger of both hands. Do not forget the back side of the last tooth on both sides, upper and lower.

When you are done, rinse vigorously with water to remove plaque and food particles. Do not be alarmed if during the first week of flossing your gums bleed or are a little sore. If your gums hurt while flossing you could be doing it too hard or pinching the gum. As you floss daily and remove the plaque your gums will heal and the bleeding should stop.

Caring for Sensitive Teeth

Sometimes after dental treatment, teeth are sensitive to hot and cold. This should not last long, but only if the mouth is kept clean. If the mouth is not kept clean the sensitivity will remain and could become more severe. If your teeth are especially sensitive consult with your doctor. They may recommend a medicated toothpaste or mouth rinse made especially for sensitive teeth.

Choosing Oral Hygiene Products

There are so many products on the market it can become confusing and choosing between all the products can be difficult. Here are some suggestions for choosing dental care products that will work for most patients.

Automatic and "high-tech" electronic toothbrushes are safe and effective for the majority of the patients. Oral irrigators (water spraying devices) will rinse your mouth thoroughly, but will not remove plaque. You need to brush and floss in conjunction with the irrigator. We see excellent results with electric toothbrushes called Sonicare and Braun Oral-B.
Some toothbrushes have a rubber tip on the handle, this is used to massage the gums after brushing. There are also tiny brushes (interproximal toothbrushes) that clean between your teeth. If these are used improperly you could injure the gums, so discuss proper use with your doctor.

Fluoride toothpastes and mouth rinses if used in conjunction with brushing and flossing can reduce tooth decay as much as 40%. Remember, these rinses are not recommended for children under six years of age. Tartar control toothpastes will reduce tartar above the gum line, but gum disease starts below the gumline so these products have not been proven to reduce the early stage of gum disease.

Anti-plaque rinses, approved by the American Dental Association, contain agents that may help bring early gum disease under control. Use these in conjunction with brushing and flossing.

Your periodontist is the best person to help you select the right products that are best for you.

Professional Cleaning

Daily brushing and flossing will keep dental calculus to a minimum, but a professional cleaning will remove calculus in places your toothbrush and floss have missed. Visit your periodontist, as he or she is an important part of your program to prevent gum disease. Keep your teeth for your lifetime.
 

 

 

 

 

 

  

 

 

 

 

 

 

 

 

 

 

 

 

 


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