Locally Delivered Antibiotics and Periodontal Maintenance

QUESTION: While treating a periodontal maintenance patient, a substitute dental hygienist suggested that locally delivered antibiotics (LDA) should not be placed without first performing scaling and root planing. This patient had undergone scaling and root planing a year ago but was just scheduled for maintenance. What is the correct protocol?

ANSWER: Periodontal maintenance does not preclude the ensuing use of LDA, as needed. Areas that exhibit bleeding on probing at subsequent maintenance appointments may be considered for adjunct therapies such as LDA, but it should follow definitive instrumentation to eradicate the root cause of the problem—burnished calculus. As locally applied antimicrobial agents are only a temporary means of controlling inflammation in specific sites, the larger questions should be, “What is the reason behind pockets that aren’t responding? What is causing the chronic inflammation?”

Gram-negative toxins overlying mineralized root accretions are the source of chronic inflammation. A pocket that does not resolve and continues to bleed does so because of the pathogenic bacteria held in proximity to the soft tissue by its scaffold of burnished calculus. Until the burnished calculus is removed, the site will continue to exhibit chronic inflammation. At some point, the oral health professional must consider what can be done to eliminate the problem rather than simply placing a bandage over it. The approach must consider that previous attempts to remove the offending root deposit have failed.

Early in my clinical practice, I would see bleeding on probing as a signal that patients were falling short in their efforts to perform adequate oral self-care. I would make a mental note to find a better method or oral hygiene implement when I debriefed them on the status of their health with self-care instruction. It didn’t take long to realize that the source of the bleeding had nothing to do with their self-care and everything to do with my clinical care, ie, instrumentation. Research findings of endoscopy confirm this, as the pilot study found the adequacy of self-care to be negligible to the overall improvement in probing scores and nonsurgical pocket elimination.¹ Creating a root surface biologically compatible with health requires the removal of the mineralized scaffold for biofilm. As such, the dental hygienist’s focus must be on skillful instrumentation.

There is nothing more challenging than working along fluctuating and often unpredictable root contours—blindly (unless your practice has a dental endoscope). Given the expertise required to maneuver smallbladed instruments in the periodontal space, it’s a bit of a miracle we are able to reach favorable outcomes with any certainty. Dental hygienists must approach this challenge by working smarter, not harder, in order to facilitate clinical success.

Recalcitrant Inflammation Protocol (RIP) is a systematic nonsurgical approach to the most difficult challenge in the clinical realm: chronically inflamed, nonresponsive pockets. This protocol will be discussed in an upcoming issue of Dimensions of Dental Hygiene.