Editorial opinion on systemic antibiotics

Dr. Andrea Mombelli, a noted researcher in the area of systemic antibiotics and Department Chair at the University of Geneva in Switzerland was invited to respond to the pilot study finding systemic antibiotics as effective as scaling and root planing. He was published in the same issue of the Journal of Clinical Periodontology.

There certainly is reason to consider the possibility of antibiotic-only therapy for chronic periodontitis. The first report of the periodontal effects of metronidazole used without sub- gingival instrumentation was published in 1962 in a medical journal. It seems a female patient being treated for vaginitis with metronidazole reported a double cure, as her “acute marginal gingivitis” was eliminated at the same time. Since that time, antibiotics have been used as an adjunct to mechanical therapy, and not as a stand alone treatment. This, despite the fact that antibiotics are being taken thousands of times each day worldwide, without subgingival debridement. These antibiotics are being taken for medical reasons.

For those with access to dental hygienists and periodontists, mechanical therapy is convenient. For people in parts of the world not served by adequate numbers of dental professionals, systemic antibiotics may provide a cost effective way to treat periodontal disease. The findings thus far challenge the central paradigm of contemporary periodontics: the role of mechanical instrumentation as the primary treatment. The low cost of antibiotics versus mechanical instrumentation has the potential to bring some periodontal treatment to people in developing or underdeveloped countries. The use of antibiotics alone may be considered as a treatment option if further research proves the old idea of requiring instrumentation before antibiotics is flawed.

Clinical Implications: Dr. Mombelli’s comments provide the profession with food for thought in the antibiotic-only discussion.

Mombelli, A.: Heresy? Treatment ofr Chronic Periodontitis with Systemic Antibiotics Only. J Clin Perio 33: 661-662, 2006.

Endo treated teeth at risk

One-stage, full-mouth disinfection explained

Several researchers have investigated subgingival instrumentation within 24 hours rather than the traditional quadrant approach. Some find the healing better than the standard quandrant approach, others find both approaches equivalent. Some studies have included either power scalers or hand instruments and some have used strong antimicrobials at the time of instrumentation and for several months afterward.

Researchers in Belgium reported their first study on this subject in 1995, followed by several more reports. This study compared the one-stage, full-mouth disinfection with a variety of chlorhexidine (CHX) and fluoride products to a quadrant approach that allowed for maximum cross-contamination between sites.

Study subjects were randomly assigned to one quadrant group of 15 subjects and four one-stage groups, each with 14 subjects. The quadrant group was treated with hand instruments at two-week intervals and oral hygiene was instructed after completion of the instrumentation. Subjects began interproximal oral hygiene in the final quadrant six weeks after the start of treatment.

Subjects in the one-stage groups all received instrumentation with hand instruments within 24 hours, plus extensive oral disinfection at that time, including: subgingival irrigation with 1% CHX gel three times within 10 minutes, tongue brushed with CHX gel, and two one-minute rinses with 0.2% CHX. This disinfection routine was repeated one week later for all four one-stage groups. The four one-stage groups included: 1) no further antimicrobials, 2) 0.2% CHX rinse for two months, 3) fluoride rinse for two months and 4) 0.2% CHX rinse for two months, followed by four months of fluoride rinsing.

Differences between the quadrant and one-stage without post-treatment rinsing were comparable. Rinsing with fluoride provided no added benefit over the one-stage instrumentation alone. The groups using a CHX rinse post-treatment did show greater healing.

Clinical Implications: Use of several forms of chlorhexidine in concentrations higher than available in the USA immediately following full-mouth instrumentation and for at least two months following instrumentation may enhance healing.

Quirynen, M., De Soete, M., Boschmans, G., Pauwels, M., Coucke, W., Teughels, W., van Steenberghe, D.: Benefit of “One-Stage Full-Mouth Disinfection” Is Explained By Disinfection and Root Planing Within 24 Hours: A Randomized Controlled Trial. J Clin Perio 33: 639-647, 2006.

Full-mouth ultrasonic debridement

Flossing compliance still poor

Flossing compliance is nortoriously poor, despite the best efforts of dental professionals worldwide. Professional dental organizations recommend daily flossing, but in reality, most people do not floss regularly. Researchers in Berlin, Germany conducted a six-week, non-experimental design interview study to measure psychological aspects related to flossing compliance. Subjects were asked about flossing habits, instructed to floss and given Oral-B Satin Floss samples, and were required to provided written answers to questions about flossing compliance and psychological aspects related to compliance. The study began with 258 undergraduate psychology and education students who were recruited for the study during regular lecture classes for the first data collection point, followed by two questionnaires sent through the mail. A high dropout rate was experienced in this study, with only 181 returning the second questionnaire and 157 completing the third questionnaire.

At baseline, 18 out of 258 students reported daily flossing. Even in this short-term study, flossing compliance was poor, and gains seen at two weeks were lost four weeks later. Despite the potential for the Hawthorne Effect of better compliance due to participation in a study, compliance was disappointing.

Clinical Implications: Getting people to floss daily requires more than technique instructions. It may be more successful with a patient-driven, change-in-routine plan in place, with strategies to deal with obstacles to compliance.

Schüz, B., Sniehotta, F.m, Wiedermann, A., Seemann, R.: Adherence to a Daily Flossing Regimen in University Students: Effects of Planning When, Where, How and What to do in the face of Barriers. J Clin Perio 33: 612-619, 2006.