A Practical Guide
Stephen Candio, DDS
Part I of this two-part series reviewed current treatments for adult periodontitis and discussed Actisite® (tetracycline hydrochloride) Periodontal Fiber (Procter & Gamble/Alza Partnership), a site-specific antibiotic fiber therapy that is indicated as an adjunct to scaling and root planing in the treatment of adult periodontitis. As stressed in Part I, the dental hygienist should play an important role in Actisite® treatment, including a critical role in patient education. In fact, it is likely that the patient will first hear about the existence of Actisite® from the hygienist.
This role will not be a major departure from current practice for most hygienists, who are already involved in designing and implementing patient education programs. In fact, in my office, I encourage hygienists to engage in a running commentary during their screening and therapy procedures, explaining the procedures being performed and making use of the time to further educate the patient on how to maintain optimum oral health. Likewise, most hygienists are certainly used to answering patient questions about oral health.
Since Actisite® was introduced in 1994, you may not have had the opportunity to perfect your question-answering skills in this particular area. In addition, as also reviewed in Part I of this article, Actisite® offers an additional therapy option indicated for patients who have not demonstrated appropriate response to scaling and root planing and present with localized areas that continue to bleed on probing. Such patients will often benefit from more extensive education about the nature of periodontal disease and the various treatment options available.
In order to provide you with the information you will need to educate your periodontally involved patients and begin to develop your own education program about Actisite®, this article presents fifteen common questions that you are likely to encounter.
Each question is followed by a list of key points plus sample answers you can use and adapt to your particular presentation style and office policy. In their entirety, these questions and sample answers include a review of the basic facts concerning periodontal disease as well as specific information on Actisite®. As such, at least part of this material undoubtedly covers areas you already present as part of your patient education programs. The purpose of including it here is two-fold: (1) to reinforce that Actisite® therapy is part of a comprehensive program of care for periodontal disease, and (2) to provide you with ideas you can combine with your current educational presentation when adapting it for Actisite® patients.
Another consideration is how you can best use this information. Some hygienists may use this information to answer questions as patients ask them. However, in our practice, we have found that an even better approach is to cover these areas as you perform your screening and introduce the possibility of Actisite® treatment to appropriate patients. Your approach will depend on what feels comfortable to you and the philosophy of your practice as regards Actisite® treatment. So that your office staff presents a united attitude toward Actisite® to the patient, I suggest that the hygienist(s) and dentist(s) discuss these questions and answers before engaging in discussion with patients
Questions on Periodontal Therapy
Q: What is gum disease? Is it serious?
Key Points: Gum disease is an infection, which if left untreated may result in tooth loss.
A: Gum disease is an infection of the tissues of the gum and the deeper underlying tooth-supporting structures. If left untreated, it may progress and cause a number of serious problems, including pain and tooth loss. Gingivitis is an early form of the disease where only the gums are infected. Gingivitis is reversible, but if it is not treated it may progress to periodontitis (pyorrhea), which also involves the gum attachment and bone tissues that support the tooth. If these tissues break down, tooth loss may result. In fact, gum disease is a leading cause of tooth loss in adults. Right now, I`m concerned because I see bleeding in and around the gums of your teeth, and that`s a sign that gum disease is present. Bleeding of the gums is a sign of inflammation and might indicate that an infection is present. If the inflammation and infection get bad enough, you get periodontal pockets.
Q: What`s a pocket? Why is this important?
Key Points: Teeth are surrounded by a collar of tissue, which when infected pulls away from the tooth to form pockets. Pockets are too deep to be effectively cleaned by even the best home care.
A: Your teeth are each surrounded by a collar of tissue that reaches up and around the tooth. [To illustrate, you may want to show the patient a tooth and gum model. Another good technique is to show your hand coming out of a sleeve, with the hand being the tooth, and the sleeve being the gums.] Saliva and food debris and germs easily get into this collar area. When your gums are healthy, the "collar area" - called a sulcus - isn`t very deep - only about 0 to 3 millimeters, or up to the thickness of three dimes. This is a depth that most people can clean effectively with brushing and flossing. But when a sulcus becomes inflamed because of decomposing food debris, bacteria, and the bacterial toxins, the tissues become swollen and pull back from the tooth, and the collar area becomes deeper. When it is diseased like this, we call that collar area a "pocket." These pockets can gradually get deeper. No matter how well you brush and floss, you can`t keep them clean, and the infection just gets worse and worse. Then the teeth get loose, and pus and abscesses can form.
Q: Can it (the periodontitis, the pockets, etc.) get worse?
Key Points: If left untreated periodontal disease may get worse.
A: Absolutely! That`s the danger. Right now the pockets that I see are about ___ millimeters deep. But they can get much worse - I`ve seen pockets up to twelve millimeters deep - and at that depth the teeth are usually loose or the patient has already lost some teeth. Painful periodontal abscesses also may develop in deep pockets. But, of course, that`s usually with patients who haven`t received treatment and who have neglected their oral health. The important thing to remember is that this can happen if the disease is ignored. It won`t get better on its own. And in fact, the disease can be tricky. It`s what we call site-specific and episodic. That means that different areas can get infected at different times. And the degree of infection can be different in different places. That`s why a good plan of treatment by a dental professional is so important.
Q: Why me? Why did I get gum disease?
Key Points: The infection is caused by bacteria. Genetic susceptibility and environmental factors help determine who actually gets the disease. Note that we suggest you assume that the patient`s home care is as good as it will get, and structure your answer accordingly. It`s rare that a patient with poor home care habits will be able to change them permanently.
A: We`re not certain why some people are more affected than others. The infection itself is caused by different types of bacteria, but genetics and environment both appear to play a role in determining who gets the disease, how severe it is, and who doesn`t get the disease. Your ability to brush and floss properly are most important. That`s why we talk about them so much. But if you`re doing the best job you can and still get the disease, it`s probably because of genetics. Scientists have found that everyone has a different resistance to the disease-causing organisms, and that`s passed on to you by your parents, and nothing will change that. Your resistance may decrease with age, stress ... or with other health factors. It`s a lot like how some people never seem to catch a cold while others catch everything. It`s just the way their bodies work. Gum disease is the same way. Since we see indications of the disease in your gums, (bleeding areas and pockets) that means you have some susceptibility. The key now is to treat those diseased areas plus to make sure you do everything you can to reduce your natural susceptibility. Basically that means doing the very best job possible brushing and flossing. Remember, "you don`t have to floss all your teeth, just the ones you want to keep." Seriously, we`ve got some very effective treatments for the gum disease, and your good home care can go a long way to reduce your susceptibility.
Q: What are my options?
Key Points: Immediate treatment is much better than ignoring the disease or waiting until it reaches a more serious level. Actisite® is a possible adjunctive treatment.
A: Well, one option is to do nothing, and your gum disease will almost certainly get worse - not a wise choice! Second, you can opt to treat it right away, as soon as we`ve found it. This will allow us to use the most conservative treatment and will probably give you the best long-term results. Or third, you can wait until it gets worse. At that point, of course, the treatment will probably be more complex, more expensive, and potentially more painful, because there will be more damage to be corrected. And of course, you always run the risk that irreversible damage will have occurred. Naturally, we suggest treating the disease now, at an early stage. From what I see here, you may be a good candidate for further treatment. This will probably include scaling and root planing and, based on your tissue response, an adjunctive treatment called Actisite® that has been very successful in controlling gum disease at this stage.
Q: Why should I do anything? Nothing hurts. It only
bleeds a little.
Key Points: Gum disease is a chronic and progressive condition. It doesn`t hurt until its very advanced stages. Any bleeding is a sign that something is wrong and that treatment is needed.
A: Well, the main thing to remember is that gum disease is a chronic and progressive disease. In its early stages, it has few symptoms. You`re correct that at this stage it doesn`t hurt - and probably won`t until its more advanced stages. If it`s ignored, however, serious permanent damage may result. It`s a lot like the subtle onset of symptoms associated with diabetes, or high blood pressure, or glaucoma in that respect. You`re actually lucky that your gums are bleeding, because that`s helped us to catch this problem early. As to the fact that the bleeding is minimal, remember that gums are just pink skin. And, just like your skin, any bleeding indicates that something is wrong. Just imagine how upset you`d be if you were taking a shower and noticed that your arm was bleeding. Wouldn`t you want to find out what the problem was right away and have it taken care of?
Q: What if I do nothing?
Key Points: Eventual tooth loss may occur in addition to painful abscesses and bad breath.
A: Without any treatment, there is a chance you may lose teeth. In addition, you`re likely to also experience painful gum and tooth abscesses, and your breath will smell foul. It`s a very unpleasant disease.
Q: What is Actisite® treatment?
Key Points: Actisite® is an adjunct to scaling and root planing. It allows an antibiotic to be placed locally in the area of infection for a period of 10 days.
A: Actisite® is a special fiber - which looks a bit like dental floss - that is impregnated with the antibiotic tetracycline. Before using it, we will perform scaling and root planing on the affected teeth. This is different from a preventive cleaning, and it removes calculus (tartar) - the hardened debris - from beneath the gum line in the pocket. Sometimes scaling and root planing combined with good brushing and flossing at home will control the symptoms of the disease for now. But if not, when you come back in about 3 weeks, the Actisite® fiber will be placed around the tooth and into that pocket area where signs of the disease are present. This allows us to place a specific dosage of the antibiotic right in the problem area where the bacteria is growing and causing problems - somewhat like putting antibiotic ointment on a cut. After 10 days, you come back and we remove the fiber. And usually, we see significant improvement indicating that the symptoms of the disease have been controlled for now. After that we`ll want to follow you very closely to check for any recurrence of disease.
Q: How long is it going to take?
Key Points: The placement and removal of Actisite® are relatively quick procedures. Use your standard scheduling practice and the extent of disease present for guidance in providing approximate times.
A: The scaling and root planing will take about ____ [insert time appropriate to the area to be treated]. That can be done ______ [at today`s visit or at a visit later this week, depending on size of the area and office scheduling]. Placing the fiber typically takes about 20 to 30 minutes, and fiber removal usually only takes about 10 to 15 minutes. Then you`ll be back in for follow-up appointments every 3 months or so at first, to continually evaluate your periodontal status.
Q: Will it hurt?
Key Points: Actisite® treatment is usually not painful.
A: My analogy is that when the Actisite® is being placed it feels like the gum is being touched with the handle end of a dental mirror. It may feel odd but usually doesn`t hurt except in very sensitive patients. For those patients, a local anesthetic is used to eliminate any discomfort. Once the fiber`s in place, the treated area will feel strange - because the fiber and dental glue that hold it in place make the area a bit bulky - but it typically doesn`t hurt. The most common adverse events noted in clinical trials were discomfort on fiber placement (10%) and local erythema (redness) following removal (11%).
Q: What does it cost?
Key Points: Follow office practice in deciding whether or not to quote an exact price, or defer that to the dentist.
A: Our office price includes placing the Actisite® plus the follow-up removal visit about 10 days later and averages about $_____ per tooth. We`ll only know for sure how many teeth will need the Actisite® treatment after we see the results of your scaling and root planing procedure and evaluate your daily brushing and flossing ability. The better your oral home care, the less we will need to treat.
Q: Will my insurance pay for it?
Key Points: The first priority is to make sure the patient receives the needed treatment. This needs to be stressed because not all insurance carriers cover Actisite® treatment yet.
A: It takes a while for many insurance companies to approve procedure changes and, because Actisite® only became available in late 1994, some insurance carriers cover it and some don`t cover it yet. Regardless of your particular insurance coverage, this is treatment we recommend in order to keep your teeth and gums health.
Q: How soon can I eat?
Key Points: Patients should not brush, floss, or chew on Actisite®-treated teeth while the fiber is in place.
A: You can eat as soon as you leave the office after the Actisite® is placed. The only thing we ask is that you avoid chewing in the area where the Actisite® is placed to avoid dislodging it. Similarly, we`ll be asking you not to brush or floss the affected teeth while the Actisite® is in place. Ten days later, as soon as the fiber is removed, you can go back to all your normal activities and home care regimen, with no restrictions whatsoever.
Q: Will this heal the disease? For how long?
Key Points: Actisite® is not a cure all, but it is an effective treatment and the next logical and most conservative treatment available following scaling and root planing.
A: Almost no treatment can be guaranteed 100% forever. But I can tell you that, following scaling and root planing, Actisite® is the next logical and conservative treatment available for your gum disease. In conjunction with scaling and root planing it has been very successful against symptoms of the disease in many patients just like you. So we`re hopeful that it may control the problem sites that we presently see.
Q: Will the pockets come back?
Key Points: Gum disease is chronic, and recurrences are not uncommon. The best weapon against recurrence is good home care plus regular recare visits.
A: Possibly. You can decrease that possibility with good home care, but gum disease is a chronic condition and pockets can come back or develop in other areas of your mouth despite all your best efforts. It depends on your personal resistance, your home care, and maintaining the recare schedule we recommend. That`s why we`ll be following you very closely after treatment, with screening and cleaning appointments every three months or so. This will allow us to spot any recurring problem immediately and treat it promptly. Although every individual is different, given proper home care, the effects of Actisite® have been shown to last for at least 6 months.
Please see accompanying brief summary of side effects and contraindications on page 29.
