Georgia Periodontics, P.C.

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. [back to top]

PerioChip ready to slip under gum into pocket

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.

Close-up of Arestin powder being expelled from syringe tip

Arestin being expelled under the gum and into the
periodontal pocket

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.