Dental Oral Wound Clinic
Recognition of the Oral/Systemic connection via the inflammatory pathway shifts scientific paradigms and challenges our profession. The science has proven the association between periodontal disease as a possible cause for cardiovascular inflammation as the American Heart Association has already placed a label of “level A” upon the distinction. With that in mind the important question is how we can control the periopathogens and whether this control will mitigate the systemic inflammation. This question is complicated by the unprecedented concerns about over usage of systemic antibiotics.
For decades treatments in both medicine and dentistry have centered on the usage of antibiotics in the treatment of bacterial infected wounds. Yet a common prescription for an antibiotic is now fraught with problems as there are multiple antibiotic resistant strains of microorganisms. This resistance has been called one of the worlds’ most pressing public health problems according to the Centers for Disease Control and Prevention[i].
The CDC reports the number of bacteria resistant to antibiotics has increased in the last decade. Many bacterial infections are becoming resistant to the most popular and commonly prescribed antibiotic treatments. Part of this is due to the unnecessary and overuse of antibiotics. Every time a person takes an antibiotic the sensitive bacteria are killed, but the resistant bacteria remain and are left to grow and multiply. This cycle continues to expand the numbers of bacteria resistant to antibiotics.
This misuse of antibiotics jeopardizes the usefulness of these essential drugs. Children are of a particular concern because they have the highest rates of antibiotic usage. Antibiotic resistance can cause significant dangers for people that have a “common” infection that could once be treated with antibiotics, but no longer can due to new resistances. The consequences are more difficult infections, longer illnesses, increased doctor or hospital visits and the need for more expensive and noxious medications. The problem has become so pervasive that there are now instances where antibiotics no longer work and patient death may result from the inability to control the cause of disease.
A widespread belief that antibiotics were/are the magic bullets to control the cause of disease is a significant problem. Parental pressure is one recognized cause of antibiotic over-usage. Pediatric care studies have demonstrated that doctors prescribe more antibiotics (62%) when the parents perceive or expect their usage as compared to a decreased frequency of prescription (7%) if doctors feel patients do not expect antibiotic prescriptions[ii]. The CDC guidelines of acute respiratory distress treatment indicate that antibiotics were prescribed 68% of the time, but of those, 80% were unnecessary[iii].
The CDC and medical associations have developed guidelines for treatment of disease which demonstrate an awareness of the antibiotic resistance problems. These organizations are beginning to recommend against broad spectrum antibiotics in an effort to reduce the incidence of resistant bacterial strains[iv]. The Association for the Advancement of Wound Care has taken these guidelines to even more specific levels, recommending against systemic antibiotics except in extreme life threatening instances[v]. In light of these concerns, dental protocols with routine prescriptions of systemic antibiotics should be re-examined. One common use of oral antibiotics in dentistry occurs with periodontal treatment. Studies and papers recommend cocktails of antibiotics.[vi] While some patients will benefit and do need oral antibiotics to decrease systemic inflammatory burdens – some of which are increased with bacteremia associated with mechanical periodontal therapy – we also have effective treatment to manage ulcerated periodontal wounds that do not rely so heavily on oral antibiotic consumption.
Ulcerated periodontal wounds are similar in nature to other body wounds and dentists can learn from guidelines for wound therapy developed by the US Department of Health and Human Service for Local Wound Care and the Association for the Advancement of Wound Care. These guidelines include gently cleansing the wound area with gentle and safe agents without the use of high pressure. Topical applied antimicrobial agents should be used whenever possible in place of antibiotics. Systemic antibiotics should only be prescribed if there are clinical signs of infections that may be life threatening. Topical wound dressings are preferred over systemic antibiotics for local control of the wound biofilm and may be a combination of antimicrobial agents, such as silver-containing or collagen/oxidized dressing materials, hydrogel or other topical agents that do not cause adverse tissue effects[vii].
Hyperbaric oxygen is also advocated for topical wound therapy. Oxygen is a non-allergenic material that promotes wound healing, is antibacterial and fosters wound repair and tissue regeneration[viii]. Hyperbaric oxygen is especially beneficial for chronic wound therapy like periodontal disease, which present with a variety of pathologies, including tissue breakdown, poor blood supply and therefore inadequate oxygen of the wound bed. Hyperbaric oxygen is beneficial because it improves oxygen supply to chronic wound and therefore improves tissue healing[ix].
Dentistry has available a number of compounds to assist in oxygen delivery. One of these is carbamide peroxide, also known as urea peroxide. Urea (carbamide) peroxide is commonly recommended for the bleaching of teeth. Urea peroxide, in the presence of catalase, breaks down to urea and hydrogen peroxide which bleaches the teeth. Hydrogen peroxide breaks down to water and oxygen. Urea breaks down to ammonia and carbon dioxide, and ammonia may cause adverse tissue effects. These may include tissue irritation, corrosive effects on skin contact which may involve blistering and sloughing of tissues if the ammonia remains in contact with the tissue for a prolonged exposure[x]. For this reason, whitening trays are designed to prevent the urea peroxide from coming into contact with gingival tissues.
A tray based method commonly used to treat periodontal disease that parallels guidelines for wound care as presented by the US Department of Health and Human Services, CDC and the Association for the Advancement of Wound Care is the Perio Protect approach. Topical delivery with a prescription tray (Perio Tray®, Perio Protect LLC, St. Louis, MO), gently applies a low pressure wound cleanser and debriding agent in the form of 1.7% hydrogen peroxide to oral wounds the sulcus or periodontal pocket to assist in cleansing the wound, removing non-vital tissue, and promoting tissue healing.
Research shows that 1.7% hydrogen peroxide gel (Perio Gel®, QNT Anderson LLC, Bismarck, ND) topically applied to periodontal wounds with a customized prescription tray (Perio Tray®) reduces pathogens localized in the sulcus or pocket, decreases inflammation and pocket probing depths, and promotes wound healing.[xi] Hydrogen peroxide is able to penetrate biofilms via oxidization to decrease bacterial loads.[xii] Hydrogen peroxide can also oxygenate periodontal pockets as it breaks down to water and oxygen[xiii][xiv]. This process therefore increases the oxygen saturation to the wound tissue to help promote healing and foster tissue recovery.
This adjunctive therapeutic approach to treat ulcerative oral wounds may help reduce the need for systemic antibiotics. The gentle application of the debriding agent and wound cleanser directly to the infected oral wounds before and after mechanical therapy can help address the infectious agents and create a healthier environment where systemic bacteremia are a lower risk. This is obvious good news for patients with antibiotic allergies, serious adverse side effects to antibiotics[xv], or general aversion to taking systemic antibiotics. It is also good news for public health advocates concerned with antibiotic over usage.
Dentists who have been prescribing this delivery system for years and their office managers will be glad to know that documentation for the procedure will be a lot easier January 1, 2014 with a new CDT code: 5944 periodontal medicament carrier with peripheral seal – laboratory processed.
[i] Center for Disease Contrl and Prevention. CDC-Get smart: Fast facts about antibiotic resistance (Http://www.cdc.gov.html)
[ii] Magione-Smith, R, McGlynn EA, Elliott MN et cl. The relationship between perceived parental expectations and pediatrician antimicrobial prescribing behavior. Pediatrics 1999;103:711-18
[iii] Scott JG, Cohen, D, DiCicco_Bloom B et al. Antibiotic use in acute respriratory infections and the ways patients pressure physicians for a prescription. J Fam Pract. 2001;50(10):853-8
[iv] Grijalva C, Nuorti JP, Griffin M. Antibiotic prescription rates for acute respiratory tract infection in US ambulatory setting. JAMA 2009;302;758-66
[v] Jones, CE, Kennedy JP. Treatment options to manage wound biofilm. Adv Wound Care 2012;1(3):120-6
[vi] Systemic antibiotics in periodontitis. Slots J & Research, Science and Therapy Committee; J Periodontol. 2004 Nov;75(11):1153-65. See also van Winkelhoff AJ and Winkel EG. Microbiological diagnostics in periodontis: biological significance and clinical validity.” Periodontol 2000. 2005;39:40-52.
[viii] Kuffler DP. Hyperbaric oxygen therapy: an overview J Wound Care 2010 Feb;19(2):77-9.
[ix] Kranke P, Bennett MH, Martyn-St. James M. et al. Hyperbaric oxygen therapy for chronic wounds. Cochran
te Database Syst Rev 2012;18:4:epub ahead of publication.
[x] Canadian Centre for Occupational Health and Safety. http://www.ccohs.ca/oshanswers/chemicals/chem_profiles/ammonia.html
[xi] Putt M and Proskin H. Custom Tray Application of Peroxide Gel as an Adjunct to Scaling and Root Planing in the Treatment of Periodontitis : A Randomized, Controlled Three-Month Clinical Trial. The Journal of Clinical Dentistry. 2012;23:48-56. SEM Results of Periopathogenic Control with the Perio Protect Method, Keller et al. J Dent Res 86(A): 1186, 2007.
[xii] Dunlap, T et al. Subgingival Delivery of Oral Debriding Agents: A Proof of Concept. The Journal of Clinical Dentistry. 2011 Nov;XXII(5):149-158.
[xiii] Putt MS, Proskin HM. Custom tray application of peroxide gel as an adjunct to scaling and root planing in the treatment of periodontitis: a randomized controlled three month clinical trial. J Clin Dent 2012:23(2):48-56.
[xiv]Walsh LJ, Safety issues relating to the use of hydrogen peroxide in dentistry. Aust Dent J 2000;45(4):257-69
[xv] Grady D. WhenPills Fail, This, er, OptionProveds a Cure. NYT January 16, 2013.