Dentists are confronted with a strong and consistent
organizational message that the use of systemic antibiotics to adjunctively
treat periodontitis is inappropriate. Of
the thousands of studies and research articles released since 2005 on the
subject, only a select few have been chosen to frame the message that systemic
antibiotic use has greater risks than benefits.
The vast majority of currant cited research, reports on
periodontal architecture as the success determinant. In short, some of the leadership guiding the
publication of evidence and guidelines for treating periodontal disease state
that pocket depths, recession levels, and bleeding on probing show no
significant difference when mechanical debridement is the primary therapy
rather than both it and adjunctive systemic antibiotics.
None of the evidence being presented to dental practitioners
depicts pathogen assessments both prior to and following treatment as being a
consideration for either method’s effectiveness. Dentists who are engaged in the oral systemic
movement are aware of many studies, which have shown superior local outcomes
with the use of systemic antibiotics specific for pathogens identified in a
pre-treatment test. The same are aware
that tissue architecture is not relative to the presence or absence of disease…
it is pathogen concentrations that determine the infection is in place, or not.
Periodontitis
is a Systemic Disease
Currant evidence is overwhelming that periodontal disease is
a systemic disease. Periodontal
pathogens, especially the gram negative late colonizers, are found associated
with and linked to cardiovascular disease, diabetes, and pre-term birth events to
simply name a few. Medicine and dentistry will soon learn that several of these
organisms are now causal to some cardiovascular disease and will be moved up
beyond the ‘level A’ designation.
These deadly pathogens are now established as regularly
available in a systemic bacteremia, are present in a systemic micro-biome, are
existing as dormant pathogens and in dormant micro-biomes, and are reproducing
in an atherosclerotic micro-biome. The question mainstream dentistry has to
answer… “is local debridement enough to treat these pathogens ?”
It is an established fact that periodontal bacteria cause an
increase in both local and systemic inflammation. Systemic cytokine levels can
be measured to increase and decrease as pathogen concentrations are elevated or
mitigated. The distant translocation of
these pathogens is creating an inflammatory cascade at the sites they have
populated. The overburden of
inflammatory markers and pathogens themselves has the effect to kill and or
mutate cells distant from the oral cavity.
The question mainstream dentistry has to answer… “is local debridement
enough to treat these pathogens and their inflammatory impact?”
The Medical
Model
When medicine confronts bacterial diseases of the body,
antibiotics are prescribed quickly and efficiently in the best interest of the
host. Antibiotic use to remedy bacterial
pneumonia, meningitis, tetanus, salmonella, gonorrhea, sinusitis, cholera,
urinary tract infection, and appendicitis is accomplished without decades of
professional dialogue or debate on the risks and benefits. Periodontal disease, perhaps the most
prolific human bacterial infectious disease, is seemingly held to a different
standard.
A
Risk-Benefit Discussion
Opponents of the adjunctive use of systemic antibiotics
purport that the risk of contracting Clostridium difficile [Cdiff] is too
great. The death incidence for this event is approximately 11/100,000.
Certainly that impact needs careful consideration, but also must be weighed
against the very high cardiovascular event numbers. Studies have shown that the
incidence of cardiac events increases 50% in the first four weeks following
scaling and root planning [invasive dental procedure]. The normal incidence of heart attacks in the
50 to 80 year old population is approximately 560/100,000. Those numbers could potentially go up to
870/100,000 in the four weeks after debridement with about 260/100,000 ending
in death. The cardiac numbers are from
the 2016 AHA statistics, despite not being adjusted for confounding factors; they
depict a perspective of the very large numbers of cardiovascular events
compared to Cdiff events.
Antibiotic
Stewardship and Systemic Antibiotics
The key to antibiotic
stewardship is identifying high-risk patients. Dental speakers directory Patients
whose currant overall medical history has compromised the body’s ability to
mitigate pathogens; a compromised immune response because of an ongoing
systemic burden of inflammation. In addition, recognize patients who are
genetically recessive and are incapable of warding off pathogens or even over
reacting to high-risk organisms in a way that enhances any given chronic
disease.
The appropriate use of systemic antibiotics in the treatment
of periodontal disease is to prescribe them for high-risk patients in which
high-risk pathogens have been identified. In the end, perhaps dentistry has
been under-prescribing systemic antibiotics and our patients have incurred
greater levels of chronic disease directly associated with periodontitis.
Source: http://bit.ly/2mItovd
