Wall Street Journal Article today:
WSJ Article
Antibiotic Therapies Allow Patients to Avoid Surgery By TARA PARKER-POPE THE COMMON TREATMENT for periodontal disease for years has been painful and expensive surgery. Doctors cut away the diseased gum tissue and sometimes take grafts from the roof of the mouth to help rebuild the gum line.
But a handful of new antibiotic-based drug therapies are now being used to help patients avoid surgery. One of the drugs is taken orally while the others are placed directly into the diseased pocket between the tooth and gum. Acceptance of the treatments has been slow, as many periodontists view surgery as the best defense against gum disease. Ronada Davis, a dentist at Texas Medical Center in Houston, advocates Atridox, an antibiotic gel. She has used it on about 200 patients with "great success," she says. "I have run into very few periodontists who use it," she adds. "Obviously, they want to do surgery."
Doctors estimate that 35% of people over the age of 30 have advanced periodontal disease. Signs may include bleeding or tender gums, persistent bad breath, separation of the gum from the tooth and loose teeth.
GUM DISEASE OCCURS when bacteria accumulate between the tooth and gum. Left unchecked, the disease can cause receding gums, erosion of the bone, and tooth loss. Although periodontal disease can be caused by poor dental hygiene, many patients are genetically predisposed.
The notion of treating gum disease with antibiotics isn't new. In the 1980s, some doctors promoted the idea of treating gum disease with antimicrobial mouthwashes and antibiotic pills in conjunction with frequent home and office cleanings with peroxide and baking soda. But these treatments were never widely embraced.
Today, the most common nonsurgical treatment is scaling and root planing, an intensive teeth cleaning above and below the gum line that often requires a local anesthetic. While the treatment may slow the disease, many patients still end up having surgery. Advanced cases may require surgery on the jawbone or removal of the teeth.
The new drugs have reignited interest in nonsurgical treatment. Atridox, approved by the FDA in mid-1998, is a gel injected directly between the gum and tooth, where it hardens and slowly releases the antibiotic doxycyclene over seven to 14 days before dissolving. In a study of 105 patients sponsored by Atrix Laboratories, Fort Collins, Colo., pocket depths of 5 and 6 millimeters were reduced to 4 millimeters or less in 70% of the patients treated with Atridox and a routine cleaning. Scaling and root planing alone produced similar results in 60% of the patients. A pocket depth below 5 millimeters is generally the level at which most doctors say patients can maintain their teeth and gums and stop progression of the disease.
ATRIDOX IS THE ONLY drug recommended as a stand-alone therapy -- all the others are used after scaling and root planing. AstraZeneca, of London, markets PerioChip, a time-release chip of the antibiotic chlorhexidine for inside the gum pocket. OraPharma of Warminster, Pa., is awaiting FDA approval for its microspheres that release minocyclene. It may be available early next year.
CollaGenex Pharmaceuticals of Newtown, Pa., markets Periostat, a pill with a low dose of doxycycline. The dose isn't strong enough to kill bacteria but suppresses enzymes that destroy collagen. A 190-patient study published in this month's Journal of Periodontology found that Periostat taken after a scaling and root-planing treatment does a significantly better job of shrinking disease pockets than scaling and root-planing alone. In some patients taking Periostat, progression of gum disease was 90% lower, compared with the placebo group.
The antibiotics are much cheaper than surgery. Atridox gels costs about $600 for a treatment of the whole mouth. Periostat costs about $150 for a three-month therapy. Add to that scaling and root-planing costs of $600 to $1,200. Surgery can cost up to $6,000.
Doctors, however, caution that long-term results aren't yet available and continuing study of the treatments is needed.
Later this year, Rick Niederman, who heads the office of evidence-based dentistry at Harvard School of Dental Medicine, will collaborate with Delta Dental Plan of Massachusetts on a 400-patient study comparing surgical and nonsurgical treatments. Dr. Niederman says the dental profession is moving from a surgical approach to a medical one. "We are in a transition period," he says. Neil Gottehrer, a periodontist in Havertown, Pa., and the chairman of the dental-education Web site, Dentalife.com (dentalife.com), has dedicated a course to the nonsurgical treatments. Maria Ryan, assistant professor at the State University of New York-Stony Brook, where Periostat was developed, believes more doctors will adopt the new drug therapies as more patients demand nonsurgical options.
Many doctors say the push for nonsurgical alternatives is overdue. For years, Manhattan dentist Stephen Z. Wolner has used a months-long treatment of weekly ultrasonic cleanings, antiseptic mouth rinses, oral antibiotics and anti-inflammatory drugs. He also urges the use of oral irrigators, electric toothbrushes and tongue cleaners. One patient, Frank Lowe, was told by two periodontists that his gum disease was so advanced that his teeth should be removed. Unhappy with the idea of wearing dentures in his 40s, the Long Island architect sought treatment from Dr. Wolner. Three years later, he still has all his teeth and his gums no longer bleed. "This shouldn't be relegated to the standard of alternative medicine,'' says Mr. Lowe. "It should be the norm."
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Fred McCutcheon |
