AVERTING AN IMPENDING MEDICAL CRISIS
The United Kingdom (UK)—a US ally—recently led an international charge against the global threat of increasing antimicrobial resistance (AMR). Many believe AMR to be a global threat to modern medicine. One of those sharing this belief is the UK’s Secretary of State for Health, Jeremy Hunt, who said, “Antimicrobial resistance is perhaps our biggest global health threat—it could nullify the progress of over a century of modern medicine and kill millions.” To date, 193 nations, including the United States and Canada, have signed an international referendum and committed to reducing the overprescribing of systemic antibiotic pills. As these nations lead this initiative on the international front, the dental profession can also take the lead in the healthcare industry.
As dentists, we can take this lead because we have a uniquely effective, though woefully underutilized, alternative to systemic antibiotics at our fingertips in the form of oral suspension rinse-and-spit antibiotics. Currently, the majority of dentists prescribe antibiotic pills to treat gingivitis, mild to moderate periodontal disease (PD), and halitosis when they are not responsive to traditional mechanical therapies such as scaling and root planing. Sometimes they are prescribed in a belt and suspenders fashion, just to be sure. This, despite the fact that we are well aware of the common side effects, such as the patient discomfort caused when the friendly gut bacteria are killed as collateral damage while we try to control oral infections.
Exploring the Systemic Antibiotic Alternative
Imagine using a different delivery method to overcome the downside of antibiotic pills, while still obtaining effective control of oral infections throughout the entire mouth. Dentists can indeed prescribe localized high concentrations of antibiotics that have a low systemic impact. Yet, aside from locally placed antibiotics such as Arestin and Atridox, most dentists have not considered any other alternatives.
One highly effective alternative that I’ve been using for the last 10 years involves prescribing antibiotic suspension liquids. These personalized prescription rinses can target infection sites at the subgingival level and throughout the mouth. They also pose virtually no risk of causing AMR due to the resulting high saliva concentrations of the antibiotics that kill the pathogenic oral bacteria rapidly as compared to oral pills. In the case of serious oral infections, antibiotic oral rinses can be combined with antibiotic pills for sustained and superior results. There will always be a role for systemic antibiotics. However, most of the time, moderate infections can be controlled with antibiotic rinses alone. What’s more, antibiotic pills still have an important role as a prophylactic treatment if there is a history of valve replacement, heart transplant, infective endocarditis, or heart surgery to repair ventro-septal defects before the age of 6 months.
As you read this, you may be wondering if these rinses are strong enough. In my opinion, definitely yes! In fact, antibiotics in a rinse and spit delivery method can result in a higher saliva concentration of absorbable antibiotic to an infected area when compared to antibiotic pills. This is because the concentration of antibiotics present in the saliva during the rinsing, and for a short time afterwards, is similar to the concentration of antibiotics present in the rinse. Compare this to systemic delivery of antibiotic results in low salivary concentrations and, depending upon the type of antibiotic and the salivary composition of the individual, this may be well below the minimum inhibitory concentration levels.
Another common misperception is that these anti-bacterial rinses can’t possibly penetrate the gingival sulcus. However, in the case of the OraVital System, the rinses are actually a slurry of antibiotic suspended in liquid versus just a liquid antibiotic. When used as directed, rinse particles enter the sulcus, crevicular fluid pressure drops, thus bringing these antibiotic particles deep into 6.0-mm pockets. On the other hand, a pill is diluted in 5 L of bodily fluids and not absorbed, metabolized, and excreted. Systemic pills also affect gut bacteria in a negative way as well as being hard on the stomach.
In addition, female patients commonly get yeast infections after their use. And, if that were not enough, the risk of AMR increases with each prescription because the saliva concentration is low in selecting for resistant bacteria. Metronidazole, one of the most effective narrow spectrum antibiotics for periodontal and halitosis concerns, is seldom used because of the alcohol restrictions recommended for patients taking it. Instead, alternative broad spectrum drugs such as amoxicillin are prescribed. In addition, due to its low saliva threshold, the antibiotic pill cannot penetrate the bacterial biofilms. This is because salivary minimum inhibitory concentrations are not reached, so it does not effectively treat the whole mouth colonies that reside on the tongue and in the throat. As such, reinfection occurs and, in spite of our best efforts, the oral biofilm returns to the same preoperative state in just 8 weeks. That is another reason why you have refractory cases.
So, are you going to continue prescribing pill antibiotics when you know there is another alternative that does not contribute to AMR? Oral rinse delivery can overcome all of these concerns.
Where Personalized Medicine Meets Dentistry
Another drawback of systemic pills and other locally administered antibiotics is the one-size-fits-all approach. My view has always been that you cannot effectively treat what is not accurately tested. In order to close the diagnosis/treatment loop, salivary testing for oral pathogens should be employed. The lab reports should then be used to guide the prescription of a specific antibiotic rinse that is formulated at a compounding pharmacy for the patient’s home care. This eliminates trial and error in the treatment process and significantly reduces the number of frustrated patients who may then resist scheduling follow-up visits.
Bridging the Oral-Systemic Gap
PD is being linked to an increasing list of medical conditions such as heart disease, diabetes, Alzheimer’s disease, rheumatoid arthritis, low-birthweight babies, and some forms of cancer. In fact, the Postgraduate Medical Journal recently published a study authored by Bale et al1 entitled, “High-Risk Periodontal Pathogens Contribute to the Pathogenesis of Atherosclerosis.” The study clearly states the following: “…it is reasonable to state PD, due to high-risk pathogens, is a contributory cause of atherosclerosis.” So, unmistakably, there is a strong medical necessity for treating oral infections effectively and predictably by controlling pathogenic biofilms effectively while at the same time minimizing the risk of antimicrobial resistance.
Antibiotic rinses are another delivery method that fills in the gap that oral pills cannot treat. The 2 methods can be combined for treating more serious infections with superior results. Patients prefer this safe method and, furthermore, a delivery protocol using rinses expands our options in using antibiotics wisely to treat moderate conditions, that we have often watched for too long a time, progress to serious oral health conditions with potential medical complications. Accurate microbiological tests, coupled with prescription of antibiotics using an oral rinse delivery protocol, can help dentists evolve from drill-and-fill practitioners into “physicians of the oral cavity,” thus improving their patients’ total health and quality of life.
1. Bale BF, Doneen AL, Vigerust DJ. High-risk periodontal pathogens contribute to the pathogenesis of atherosclerosis. Postgrad Med J. November 29, 2016 [Epub ahead of print]. doi: 10.1136/postgradmedj-2016-1342.
Dr. Hyland is a graduate of the University of Toronto (U of T). In addition to private practice, he teaches at U of T Faculty of Dentistry, Seneca College, and George Brown College. He has also served as a dental staff member at North York Hospital, Ontario. He lectures internationally and has written for a number of publications on a variety of topics related to the diagnosis and treatment of periodontal disease as an oral infection, interceptive preventive care, and decreasing the oral-systemic risk and breath odor. In 2008, Dr. Hyland’s practice became the first OraVital-certified clinic. He can be reached via email at firstname.lastname@example.org.
Disclosure: Dr. Hyland has been the president and CEO of OraVital Incorporated since 2014 and is a shareholder.