New horizons in periodontal pharmacology

May 1, 2000
The future of treatment for chronic periodontitis in adults looks brighter than ever thanks to an arsenal of anti-bacterial weapons.

The future of treatment for chronic periodontitis in adults looks brighter than ever thanks to an arsenal of anti-bacterial weapons.

Arlen D. Lackey, DDS

Many general dental practitioners implement health-maintenance programs for periodontal tissue, allowing their patients to retain a greater number of their teeth for a lifetime. The office equipped for the 21st century uses electronic clinical records that create an effective system of information flow, decision-making, and treatment for chronic adult periodontitis, as well as other dental conditions. Follow-up care will be enhanced by the same digital systems.

A recently introduced arsenal of anti-bacterial weapons - the site-specific antimicrobials - provides significant improvements for patients to control and, someday, hopefully conquer periodontal disease. Antimicrobial therapy can improve levels of dental health as a new integrated periodontal service for patients. The science and research is clear - the results are impressive! When and how can general dental practitioners best employ these exciting advances in nonsurgical periodontal therapy and digital technology?

Guidelines for periodontal diagnosis and non-surgical therapy have been developed by the American Dental Association and the American Academy of Periodontics. These guidelines are readily available in print form or can be downloaded via the Internet. After being informed, dental practitioners have the responsibility to communicate the improved periodontal health benefits that site-specific antimicrobial therapy can offer.

Practice-building with site-specific antimicrobials is a new opportunity to greatly improve the periodontal health of your patient base. These triumphs encourage patients to refer family and friends, which, in turn, benefits the growth of your practice. Taking advantage of these new research breakthroughs in the treatment of periodontal disease can elevate productivity while lowering overhead. This, in return, can improve the financial management and performance of each dental practice.

A bigger vision

Couple the periodontal therapy breakthrough with the computer technology in the treatment room. Multimedia digital presentations (CD-ROM and DVD) combine sound, graphics, photos, and animation to encourage more rapid decision-making. Integrating and networking computers throughout the office is a desirable goal during the next few years.

Chronic adult periodontitis is a condition that impacts a majority of adults in all dental offices. Patient education for the traditional "what, why, when, and where" of periodontal disease has been simplified with computer dental management systems.

In the management and control of periodontal disease, periodontal pocket-charting and the number of inflammation (bleeding) sites are key components of discovery, education, and treatment, including follow-up care. The growing role of computers in the treatment room facilitates record-keeping with voice-activated, periodontal-charting software.

The process

Patients are scheduled for an initial periodontal evaluation (IPE) visit with a registered dental hygienist. The periodontal charting of pocket depths and bleeding points can be accomplished in many ways, but utilizing voice-activated software permits this information to be obtained in four to five minutes by a single individual. This is a worthy labor-saving cost!

Computer monitors can be located conveniently in front of the dental chair for easy viewing. Now available on CD-ROM or DVD, digital patient-education systems, such as the ones available from the ADA, CAESY®, etc., permit rapid patient decision-making to take place in just a few minutes. A picture is truly worth a thousand words!

Following a clinical examination with the periodontal records, the dentist then informs the patient about treatment options. Chairside communication about the need for root-planing and the role of site-specific antimicrobial treatment can be done at this time.

Acute and advanced cases of periodontal disease may be referred to a periodontist. Recently, chronic periodontitis in adults has been treated with varying degrees of success with scaling and root-planing, followed by periodontal surgery, if needed. The recent option of the pharmacologic antibacterial and site-specific treatments opens new chapters in therapy. Antibacterials help destroy the bacteria, the cause of chronic periodontitis in adults.

New pharmacology treatment

Three new pharmaceutical products have been approved by the FDA for the treatment of periodontal disease. The three are Periostat® (CollaGenex Pharmaceuticals), PerioChip® (Astra, Inc.), and Atridox® (Block Drug Company). They each play a somewhat different role in the pharmacologic counterattack to the disease process. Atridox® is the only microbial agent that carries the ADA Seal of Acceptance.

Periostat® is recommended as a systemic means to inhibit the enzymes which destroy the periodontal-tissue resistance to pathogens. It is administered by a tablet and is taken twice daily. It permits a low dose of the antibiotic, doxycycline, to stimulate and enhance the immune system`s resistance to the attack of pathogens.

Patients with a history of chronic bone loss or lack of long- term healing may be candidates for repeated doses of the systemically taken Periostat®.

Quantity of product and economics play a role in choosing between the two site-specific antimicrobials, PerioChip® and Atridox®. PerioChip® is a semi-solid form of chlorhexidine gluconate in a gelatin matrix. It can be placed in various periodontal pocket locations. For a few periodontal lesions, it is an effective, comfortable way to heal diseased pockets. A patient fee range for the PerioChip® among general practitioners is $35-$50 per pocket treatment. (each chip) This generates a modest income for the dental practice.

Atridox® is the site-specific medication of choice for chronic adult periodontitis with generalized and/or multiple-pocket areas needing treatment. In addition, the mixing and dispensing capability of the Atridox® syringe supplies doxycycline in a flowable form for many scattered pockets or an entire quadrant of teeth. The medication will control site-specific infection in 48-72 hours, and it will continue its effectiveness for weeks thereafter.

From my experience of more than 350 quadrant applications of Atridox® in over 150 patients, I can share some exciting periodontal-health results. My dental team and I have observed dramatic, prolonged healing and pocket reduction for anywhere from six to 12 months.

The learning curve to administering Atridox® can be mastered after six to eight applications. It may not always be necessary to actually fill the pocket - absorption of doxycycline gel through the epithelial and mucosal tissues is very effective. In more shallow pockets, placement of the antibiotic gel around the necks of the teeth can measurably achieve healing. A perio dressing, such as CoePak®, is occasionally needed to cover the gel and hold it in place from strong tongue muscle activity. If the patient has mild to moderate periodontal problems, leaving Atridox® in for only three to four days seems to clinically obtain results similar to leaving it in for six to eight days. The shorter term greatly enhances patient acceptance, given the more hectic pace of everyone`s schedules. Deeper pockets can benefit from the dissolving of Atridox® over seven to 30 days inside of the pockets.

Improving health and income

General practitioners` fees for Atridox® range from $100 to $150 per quadrant and/or syringe. Many patients prefer treating half their mouth at one visit. Some prefer treating the entire mouth at one visit, where appropriate. In many offices, it is common to treat four to six quadrants daily.

If you choose an average of five quadrants of Atridox® therapy - at the fee range discussed above - this would generate $500 to $750 daily. Using a four-day work week and an 11-month appointment schedule, site-specific Atridox® therapy can generate $22,000-$33,000 yearly. Your patients benefit from a comfortable, low-cost, periodontal treatment to help save their teeth for a lifetime. For many general practitioners, it is an opportunity to add more quality and comfort of care to patient treatment, and, at the same time, providing a worthy, additional source of income for the practice.

At recare visits in 30 to 90 days, follow-up periodontal records are obtained. These can be generated by computer software that is voice-activated and printed for patient viewing on inexpensive ink-jet color printers. Dental practitioners will find that most of the time they will observe profound healing results.

The best is happening now

Varying combinations of the three pharmacologic agents discussed in this article can be utilized to create healthier results in the periodontal tissues. Clinical experience and additional research may disclose that the surgical approach to the treatment of periodontal disease will markedly decrease in the years ahead, just as chemotherapy has reduced the need for cancer surgery. Judicious use of these new antimicrobial agents will not only improve the periodontal health and quality of care for the patient, but will contribute to the revenue income of the practice.

The role of digital technology continues to grow in importance in our dental offices. Computer- OsmartO workstations in each treatment room efficiently collect patient records, forming detailed electronic files. More comprehensive records allow for better diagnosis and improved treatment-planning. Digital records also improve patient communication and clarity. Both are keys in enhancing patient management and office productivity. The final result can be increased office income, higher quality of care, and improved service to the patient.

For more information about this article, contact the author by phone at (831) 649-1055. A biography of the author appears on page 10.

Treatment protocol for chronic adult periodontitis

x Detection, education, diagnosis

x Scaling, root-planing

x Pharmacologic antimicrobials

x Patient follow-up in 30 to 90 days with updated periodontal records

x Referral for periodontal surgery may be a patient choice.

x Repeat the use of pharmacologic antimicrobials as an alternate patient choice to surgery.

Action plan for periodontal health

x Integrated - team, technology, pharmacologic therapy

x Networked - Digital clinical records and X-ray images

x Focused - Doctor/staff teamwork and treatment-planning

x Comprehensive - Periodontal treatment and maintenance approach

x Communicating - Continuing digital patient education and records

x Caring - Human touch and follow-up from a motivated office team

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