Reduce the need for supportive antibiotics during scaling and root planing

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There has been much attention in the literature and news regarding the overuse of antibiotics in medicine and dentistry. For example, it was recently reported that antibiotics were administered to 30% of elderly patients receiving Medicare benefits during outpatient visits for COVID-19 from April 2020 to April 2021, even though antibiotics are ineffective treatments for viral syndromes, including the virus that causes COVID -19.1 In response, the National Institutes of Health has just awarded the University of Texas Health Sciences Center at San Antonio a four-year, $2.4 million grant to conduct a clinical trial to study the responsible use of antibiotics when treating periodontal disease.2

Periodontal disease is widespread and affects 40% of the American population. Because periodontitis is caused by oral bacteria in the plaque around the teeth, dentists often use systemic antibiotics in conjunction with scaling and root planing (SRP) of the teeth (deep cleaning) to resolve the disease. Although research shows some benefit in some patient cases of supplemental use of systemic antibiotics during PRS, it is still unclear who are the best candidates to receive these antibiotics and the risk-benefit ratio of overprescribing.3

Concerns have arisen over the indiscriminate use of antibiotics resulting in resistant strains of bacteria or superbugs. Additionally, antibiotics may be associated with considerable morbidity such as drug-induced lupus, Clostridioides difficile colitis and/or life-threatening reactions such as anaphylaxis or Stevens-Johnson syndrome.4 Finally, Alzheimer’s disease and Parkinson’s disease are neurogenerative diseases that have recently been hypothesized to be associated with dysbiosis of microbes in the gut. It is thought that because antibiotics upset the balance of the intestinal flora, they can be a triggering factor for neurological disorders, including Alzheimer’s and Parkinson’s, especially during old age when immune defenses are absent or reduced.5


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Antimicrobial stewardship programs were discussed that establish prudent administration of antibiotic guidelines in different societies in the medical and dental fields, with the aim of reducing unevidence-based over-prescribing.6 In these programs, any alternative protocol or modality that can lead to a de-escalation of unnecessary antibiotic use is advocated.

The purpose of this article is to describe a pilot study involving 10 patients with moderate to severe chronic periodontal disease scheduled for four quadrants of SRP who used the StellaLife Vega Oral Care Recovery Kit for 10 days prior to the start of periodontal treatment. . The concentration of oral bacterial pathogens was measured before using the recovery kit and then 10 days after use. An overall average reduction of 22% in oral pathogen bioburden was recorded, suggesting that use of the Oral Care Recovery Kit prior to periodontal treatment may reduce the need for additional systemic oral antibiotics during SRP treatment.

Rationale for the study

StellaLife Vega Oral Recovery Kit consists of a natural mouthwash, oral spray and topical gel containing herbal extracts from Azadirachta indicaechinacea, calendula, and propolis. The active ingredients in this treatment have been shown to have antimicrobial properties similar to 0.12% chlorhexidine without the cytotoxicity to human gingival fibroblasts and osteoblasts.seven This treatment has also been suggested to improve oral wound healing by up-regulating type I collagen transcription.8

Another recent in vitro study suggested that StellaLife Vega Mouthwash, compared to 0.12% chlorhexidine, exhibited bacteriostatic properties without the cytotoxicity and inhibition of human gingival fibroblast proliferation observed with the use chlorhexidine.9 Other notable side effects with the use of 0.12% chlorhexidine during periodontal treatment include dysgeusia, staining, increased tartar buildup, mucositis, and dermatitis.ten Based on its bacteriostatic properties and its ability to improve wound healing without the side effects seen with other medicated mouthwashes, a pilot study was created to evaluate the ability of these compounds to reduce the microbial load of oral pathogens prior to SRP to reduce the potential need for supportive therapy. systemic antibiotics.

Study

Ten patients diagnosed with generalized moderate to severe chronic periodontal disease (stage III or IV grade B)11 with a bleeding and plaque index of 3, treatment planned for four quadrants of SRP were included in this pilot study. The age range of patients in this study was 35-75 years with no current history of smoking, diabetes, and/or immunosuppressive disorders. After signing the informed consent, a saliva sample was taken from the patients and subjected to oral DNA analysis. Patients were then given a demonstration of oral hygiene instructions and given the StellaLife Vega Oral Recovery Kit. Patients were instructed to use the rinse three times a day for 60 seconds, three pumps of the spray sublingually (under the tongue) three times a day, then, with a clean cotton swab, rub the gel over the mouth and palate/lingual gingival tissue three times daily.

Oral DNA test

The oral DNA test (OraVital Biofilm Diagnostics Microbiology Lab) received measured specific types of bacterial levels from five different areas of the mouth by patient in genome copies/mL in log10 values. The bacteria measured included the high-risk pathogen red complex: Aggregatibacter actinomycetemcomitans (AA), Porphyromonas gingivalis (PG), Tannerella forsythia (TF), and Treponema denticola (TD); and the moderate risk pathogenic orange complex: Nucleated Fusobacteria (FN), Candida albicans (CALIFORNIA), Micros of Peptostreptococcus (PM), and the caries susceptibility pathogen Streptococcus mutans (SM).

Genomic DNA is extracted from the submitted sample for eight oral species associated with periodontal disease, caries and candidiasis. Bacteria are tested by quantitative polymerase chain reaction (qPCR) using an absolute quantitation method, and readings are interpreted against the standard curve for each pathogen obtained from amplification of related plasmid DNA .

Red and orange threshold levels are based on current literature and reported in log copies per sample (Figure 1). Bacterial counts above the red line mean infection, between the red and orange lines mean monitoring the patient’s progress, and below the orange line indicate within the acceptable normal range. Overall bacterial counts were recorded and compared before (Figure 2) and after therapeutic intervention (Figure 3) and reported as percent reduction, no change, or percent increase in colony count.

Results and conclusions

Ten patients with moderate to chronic generalized periodontal disease for four SRP quadrants were given the StellaLife Vega Oral Recovery Kit and shown how to use it for 10 days prior to treatment. Bacterial samples were measured before and after use of the Oral Retrieval Kit, and an overall average reduction of 22% in bacterial colony formation was recorded. This reduction in bioburden may obviate the need for administration of systemic antibiotics during initial periodontal treatment, including SRP. Since the StellaLife product is completely natural with bacteriostatic properties and is non-cytotoxic, adverse effects associated with systemic administration of antibiotics are not observed. Further research, including blinded randomized clinical trials, is needed to compare the equivalence of administering systemic antibiotics and the oral recovery kit as an adjunct to initial periodontal treatment and SRP.

References

  1. Tsay SV, Bartoces M, Gouin K, Kabbani S, Hicks LA. Antibiotic prescriptions associated with COVID-19-related outpatient visits among Medicare beneficiaries, April 2020 to April 2021. JAMA. 2022;327(20):2018-2019. doi:10.1001/jama.2022.5471
  2. Lee S. NIH awards $2.4. $1 million grant to UT Health San Antonio and the ADA Science & Research Institute to study responsible antibiotic use. UT Health San Antonio. April 27, 2022. https://news.uthscsa.edu/nih-awards-2-4-million-grant-to-ut-health-san-antonio-and-ada-science-research-institute-to-study – responsible-use-of-antibiotics/
  3. Kapoor A, Malhotra R, Grover V, Grover D. Systemic antibiotic therapy in periodontics. Dent Res J (Isfahan). 2012;9(5):505-515. doi:10.4103/1735-3327.104866
  4. May B. More selective antibiotic shows promise for hard infection. Medscape. May 6, 2022. https://www.medscape.com/viewarticle/973563
  5. Angelucci F, Cechova K, Amlerova J, Hort J. Antibiotics, gut microbiota and Alzheimer’s disease. Neuroinflammation. 2019;16(1):108. doi:10.1186/s12974-019-1494-4
  6. Lee CR, Cho IH, Jeong BC, Lee SH. Strategies to minimize antibiotic resistance. Int J Environ Res Public Health. 2013;10(9):4274-4305. doi:10.3390/ijerph10094274
  7. Zhou P, Chrepa V, Karoussis I, Pikos MA, Kotsakis GA. The cytocompatibility properties of a compound herbal solution promote wound healing in vitro. Before Physiol. 2021;12:340. doi:3389/fphys.2021.653661
  8. Fujioka-Kobayashi M, Schaller B, Pikos MA, Sculean A, Miron RJ. Changes in cytotoxicity and gene expression of a new homeopathic antiseptic mouthwash compared to chlorhexidine in gingival fibroblasts. Materials (Basel). 2020;13(14):3190. doi:3390/ma13143190
  9. Batra C, Alalshaikh M, Gregory RL, Windsor LJ, Blanchard SB, Hamada Y. An in vitro comparison of four antibacterial agents with and without nicotine and their effects on human gingival fibroblasts. J Periodontol. 2022;93(2):e24-e33. doi:1002/JPER.21-0262
  10. IBM Micromedex. Chlorhexidine (oral route). Side effects. Mayo Clinic. Updated February 1, 2022. https://www.mayoclinic.org/drugs-supplements/chlorhexidine-oral-route/side-effects/drg-20068551
  11. Tonetti MS, Greenwell H, Kornman KS. Staging and grading of periodontitis: framework and proposal for a new classification and case definition. J Periodontol. 2018;89(Suppl 1):S159-S172. doi:10.1002/JPER.18-0006. Erratum in: J Periodontol. 2018;89(12):1475. doi:10.1002/jper.10239

Editor’s note: This article appeared in the July 2022 print edition of Dental economy magazine. Dentists in North America can take advantage of a free print subscription. Register here.

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