Occasionally, a patient will ask me if whitening can damage their teeth. Damage may be prevented with certain precautions. Before whitening, have your dentist repair any cavities or fractures you may have, or whitening might make them worse. The main ingredient in whiteners is either hydrogen peroxide or carbamide peroxide (another form of hydrogen peroxide). They come in varying percentages. The higher the percentage, the quicker the whitening process, but the higher the incidence of teeth sensitivity. [Read more...]
Dental implants have become an increasingly popular way to replace missing teeth and anchor dentures in place. When an implant is used to replace a single tooth it can be one of the most natural feeling replacement options. You can floss around an implant, just like your natural tooth. This is much easier to do than flossing around and under a dental bridge. An implant is anchored into the bone, just like the root of a tooth so it stays in your mouth all the time, unlike a partial denture which is taken out at night. For a patient who wants the most realistic replacement option an implant may be the way to go. Unfortunately, bacteria can cause bone loss around implants, just like with natural teeth. This destruction around a natural tooth is called periodontal disease, around an implant it is called peri-implantitis.
Recently I saw a patient with moderate periodontal disease and two implants, one showing signs of peri-implantitis. She had a 6 mm probing depth on one implant, with bleeding. Bone loss around the implant was also visible on the x-rays that were taken. The patient was treatment planned for scaling and root planing with locally applied antibiotic therapy. While I frequently use locally applied antibiotics in practice for patients with periodontal disease I was not sure what the science said about using it around implants, so I decided this would be a great time to find out.
They type of locally applied antibiotic that I like to use is Arestin, which is minocycline, a member of the tetracycline family. I spoke to the company representative to ask her opinion. I was told, that Arestin is not FDA approved for the treatment of peri-implantitis. FDA approval is given to a drug based on research on the drug for a specific purpose. The company must submit research to the FDA that shows the drug is safe and effective for that specific purpose. The FDA reviews this evidence and decides if the benefits outweigh the risks. They don’t test the drug itself. If they approve the drug is allowed to be sold. Use of a drug for a purpose other than that specifically tested is called off label use. Doctor’s and dentists are allowed to use a drug for an off label use, many drugs are used this way. A good example is the use of antidepressant drugs as drugs to help patients sleep. (Example: Trazadone) I did learn from the representative that dental professionals have used this drug for peri-implantitis based on research that is currently available. I was also told that the company is also doing its own studies on Arestin and peri-implantitis.
Off label use of medications is not a new concept to me. I worked for many years in the field of psychology, and a lot of drugs used to treat psychiatric illnesses were developed for other reasons. Also, most of these medications were only approved for use in adults, but they are commonly prescribed to children and adolescents.
Before I began to research, or speak to reps from the company this was my thought process:
1. A bleeding pocket indicates bacteria, regardless if it is surrounding a tooth or an implant.
2. While research on teeth with periodontal pockets indicates an increase of attachment and reduction in pocket depth, it may not be the same with implants, so I need to do some research.
3. Scaling an implant is much more difficult than scaling a natural tooth because of the shape of the implant, and the instruments that can and can’t be used. Implants can only be scaled with plastic or titanium instruments. Only special plastic covered ultrasonic instruments can be used. This reduces the likelihood of removing all bacteria. I would feel much more comfortable placing an antibiotic in order to continue to kill any leftover bacteria.
- Bacteria load, 40 types including the one most commonly associated with peri-implantitis, in pockets around the implant was reduced for 180 days. 5
- Another study found similar results, but thought that it wasn’t a specific bacteria that was causing the peri-implantitis, rather it was the combination of all bacteria present as well as the amount of bacteria.4
- Greater reduction in probing depth and bleeding was found in patients who had Arestin placed, than those who used a chlorhexidine gel for treatment.6
- Patients with a history of smoking, periodontal disease, poor oral hygiene, exposed implant threads or implants that were placed into areas of reduced bone are at increased risk of peri-implantitis. These conditions should be under control before placing implants for best results. Failure rates are higher for smokers and patients with active periodontal disease. Controlling periodontal disease through a maintenance program is required to keep bone healthy. In fact, peri-implantitis progresses faster than periodontal disease, more destructive and harder to treat so proper maintenance and assessment at regular intervals is needed. When bone loss around implants are found aggressive treatment is needed. Which may include mechanical debribement, flushing with antimicrobials and antibiotic placement, possibly even surgical intervention.2
- Another study found that adjunctive photo-dynamic therapy had comparable results to locally delivered antibiotic therapy.1 Photo-dynamic therapy uses a photo-active dye which is activated by a certain wavelength of light which breaks down components of cells, including the bacteria which cause the destruction in periodontal disease and peri-implantitis.3 Unfortunately this treatment is not commonly used in practice, so you may not find a dental office that performs this therapy.
So what am I going to do for my patient? I am going to place localized antibiotic. I would like for more research to be completed so I can have stronger evidence to support the treatment, but I can’t take a chance at not doing something that will be beneficial to my patient while waiting for research to be completed. As medical professionals sometimes we have to make a call, and after doing my research and discussing it with the dentist I work with I think this is the best call for my patient.
1 Bassetti, M; Schär, D; Wicki, B; Eick, S; Ramseier, CA; Arweiler, NB; Sculean, A; Salvi, GE. Anti-infective therapy of peri-implantitis with adjunctive local drug delivery or photodynamic therapy: 12-month outcomes of a randomized controlled clinical trial. Clin Oral Implants Res, 2013.
2 Ho, Christopher CK; Tang, Teck. Failing implants, maintenance, recall. Australasian Dental Practice. January/February, 2011.
3 Konopka K, et al. Photodynamic therapy in dentistry. J Dent Res. 2007 Aug;86(8):694-707.
4 Persson, GR; Salvi, GE; Heitz-Mayfield, LJ; Lang, NP. Antimicrobial therapy using a local drug delivery system (Arestin) in the treatment of peri-implantitis. I: Microbiological outcomes. Clin Oral Implants Res, 2006 vol. 17(4) pp. 386-93.
5 G.R. PERSSON. Microbiological Outcomes of Peri-implantitis Therapy with an Adjunctive Local Antibiotics. University of Berne, University of Washington, Seattle, WA, USA, G.E. SALVI, University of Berne, School of Dental Medicine, Switzerland, L.J.A. HEITZ-MAYFIELD, University of Berne, Cottesloe, Australia, F. DOHERTY, Orapharma Inc, Huntingdon Valley, PA, USA, and N.P. LANG, University of Bern, Berne, Switzerland.
6 Renvert, S; Lessem, J; Dahlén, G; Lindahl, C; Svensson, M. Topical minocycline microspheres versus topical chlorhexidine gel as an adjunct to mechanical debridement of incipient peri-implant infections: a randomized clinical trial. J. Clin. Periodontol., 2006 vol. 33(5) pp. 362-9.