Treating the resistant infections is challenging. Take Clostridioides difficile (C diff) infections as an example. This inflammation of the colon that causes diarrhea and colitis affects almost half a million people a year in the US.[1] The bacteria releasing the exotoxins that cause tissue damage colonize the gastrointestinal tract after the normal gut flora are altered, typically after antibiotic use. A lab test can confirm the infection, but there are few options to treat it, except for powerful antibiotics and fecal transplants.

The problem is that many patients contract C diff after taking antibiotics and the subsequent antibiotics they take to combat C diff are not particularly effective. Patients are 7 to 10 times more likely to get C. diff infection while taking antibiotics and during the next four weeks following the medication. 1 in 6 patients who get C diff will get it again in the next two months. For patients with healthcare-associated C diff infections who are over 65 years of age, 1 in 11 will die within a month of diagnosis.[2]

Because antibiotic prescribing practices put patients at risk for C. diff infections and because the general overuse and over reliance on antibiotics have led to significantly greater antibiotic resistant threats, prescribing practices are at the heart of CDC antibiotic stewardship campaigns. In hospital settings, CDC estimates that 30-50% of antibiotics are unnecessarily or incorrectly prescribed. Fluent et al. identified similar numbers in dentistry.[3] A smaller study increased the unnecessary dental antibiotic scripts to 80%.[4]

Dentists are the number 3 out-patient prescribers of antibiotics, behind physician assistants/nurse practitioners and primary care physicians, and the top out-patient prescribers of clindamycin, the drug most commonly associated with C diff.[5]

A study of superbug infections in Minnesota shows how important it is that dentistry take antibiotic resistance threats seriously. The Minnesota Department of Public Health tracked 2176 C diff infections from 2009-2015 in 5 Minnesota counties. 1626 cases (75%) were confirmed, of which 57% were prescribed antibiotics prior to contracting C diff. 15% or 136 of these antibiotic prescriptions were written by dentists. The median age of dental patients was 57 years old and the most frequently prescribed drug was clindamycin. The authors conclude that “Dental antibiotic prescribing rates are likely underestimated. Stewardship programs should address dental prescribing and alert dentists to CDI (C diff Infection) subsequent to antibiotics prescribed for dental procedures.”[6]

Organized dentistry is heeding the call. Both the Organization for Safety, Asepsis and Prevention (OSAP) and the Michigan Antibiotic Resistance Reduction (MARR) coalition provide resources to help improve dental prescribing practices.[7]

Dentists also need non-antibiotic options to treat disease. Many bacterial-based diseases result from biofilm induced inflammation. Gum disease, one of the two most prevalent and underdiagnosed dental diseases, is a classic example. Periodontitis, like other biofilm-based diseases, is “refractory to antibiotic agents and host defenses because the causative microbes live in complex communities that persist despite challenges that range from targeted antibiotic agents to phagocytosis." It’s not just that the bacteria have built up resistances to the drugs, but that the biofilm community itself actively resists antibiotics. Put in other words, antibiotics are not particularly effective against biofilm-based diseases. Researchers suggest that “The regular delivery of nontargeted antibiofilm agents may be an effective strategy for treating biofilms, especially if these agents include oxidative agents that dissolve the biofilm matrix.”[8]

And oxidative agents work well when administered via deep Perio Tray™ delivery. Studies show that Perio Tray™ delivery of hydrogen peroxide effectively reduces bleeding, inflammation, pocket depths, and bacterial loads.[9]  While chlorine-based products and essential oils have shown efficacy,[10] the benefit of a Perio Protect sealed tray over rinse application is that this prescription tray can place and hold medication deep into the sulcus or periodontal pocket so that the medication can fight the infections deep below the gums where rinses can't reach. The benefit of hydrogen peroxide use is lost without the patented Perio Tray™ seal that retains oxygen below the gums to fight infection and challenge anaerobic organisms.[11]

Low concentrations of hydrogen peroxide (e.g. Perio Gel™ 1.7% hydrogen peroxide) is particularly effective because it is a broad-spectrum antimicrobial, physically disrupting the biofilm matrix that protects biofilm communities. It is additionally beneficial that bacteria do not build up resistance to peroxide as they do to antibiotics. Peroxide does more than just kill bacteria. Its release of oxygen – as it activates, peroxide turns into O2 + H2O – changes the microenvironment of the periodontal pocket so that healthy bacterial species repopulate at the expense of pathogenic ones.[12]

Let’s be honest. We've used antibiotics for decades and we still have very high rates of disease. 47% of Americans aged 30 years and older already have chronic periodontitis. By the time Americans reach 65, the number is 70%.[13]

We can do better and patients deserve better. Improving homecare is essential. For patients with gingivitis, we want to intervene at the earliest stages, address infection and prevent recurrence. For patients with periodontitis, the goal is to add effective homecare to help put the disease into remission and prevent recurrence. 

Perio Tray™ delivery of hydrogen peroxide is an excellent choice in the post-antibiotic age.

The CDC has had a comprehensive in-patient antibiotic stewardship campaign for years. They have also developed materials specifically for dental prescribing practices.

The brochure featured to the left is available for download and use with this link.

[1] Antibiotic Resistance Threats in the United States, 2019. Atlanta, GA: U.S. Department of Health and Human Services, CDC; 2019.https://www.cdc.gov/drugresistance/pdf/threats-report/2019-ar-threats-report-508.pdf. https://www.cdc.gov/cdiff/what-is.html.
[2] https://www.cdc.gov/cdiff/pdf/FS-Cdiff-PatientsFamilies-508.pdf, https://www.cdc.gov/cdiff/clinicians/index.html;

[3] https://www.cdc.gov/drugresistance/about.html; Fluent MT, Jacobsen PL, Hicks LA; OSAP, the Safest Dental Visit. Considerations for responsible antibiotic use in dentistry. J Am Dent Assoc. 2016;147(8):683-686. Palmer NO, Woodward J.

[4] https://www.cidrap.umn.edu/antimicrobial-stewardship/researchers-highlight-serious-side-effects-unneeded-dental-antibiotics.

[5] https://www.cdc.gov/antibiotic-use/data/outpatient-prescribing/index.html, https://www.cdc.gov/antibiotic-use/data/report-2021.html.
[6] Bye M, Whitten T, Holzbauer S. Antibiotic Prescribing for Dental Procedures in Community-Associated Clostridium difficile cases, Minnesota, 2009–2015. Open Forum Infect Dis. 2017;4(Suppl 1):S1. Published 2017 Oct 4. 

[7] https://www.osap.org/antibiotic-stewardship-for-prescribers, https://www.mi-marr.org/dental-resources/ .
[8] Schaudinn C, Gorur A, Keller D, Sedghizadeh PP, Costerton JW. Periodontitis: an archetypical biofilm disease. J Am Dent Assoc. 2009;140(8):978-986.
[9] Perio Gel™ with 1.7% hydrogen peroxide via Perio Tray™ delivery, Perio Protect LLC, St. Louis, MO, USA. Peroxide needs time to work. The optimal treatment time with Perio Tray™ delivery is 15-minute applications. Putt MS, Mallatt ME, Messmann LL, Proskin HM. A 6-month clinical investigation of custom tray application of peroxide gel with or without doxycycline as adjuncts to scaling and root planing for treatment of periodontitis. Am J Dent. 2014;27(5):273-284. Putt MS, Proskin HM. Custom tray application of peroxide gel as an adjunct to scaling and root planing in the treatment of periodontitis: a randomized, controlled three-month clinical trial. J Clin Dent. 2012;23(2):48-56. Putt MS, Proskin HM. Custom tray application of peroxide gel as an adjunct to scaling and root planing in the treatment of periodontitis: results of a randomized controlled trial after six months. J Clin Dent. 2013;24(3):100-107. Cochrane RB, Sindelar B. Case Series Report of 66 Refractory Maintenance Patients Evaluating the Effectiveness of Topical Oxidizing Agents. J Clin Dent. 2015;26(4):109-114. Keller DC and Cochrane B. Composition of Microorganisms in Periodontal Pockets. JOHD 2019:2(2):123-36.  
[10] Krayer JW, Leite RS, Kirkwood KL. Non-surgical chemotherapeutic treatment strategies for the management of periodontal diseases. Dent Clin North Am. 2010;54(1):13-33. Charles CH, Mostler KM, Bartels LL, Mankodi SM. Comparative antiplaque and antigingivitis effectiveness of a chlorhexidine and an essential oil mouthrinse: 6-month clinical trial. J Clin Periodontol. 2004;31(10):878-884.
[11] Dunlap T, Keller DC, Marshall MV, et al. Subgingival delivery of oral debriding agents: a proof of concept. J Clin Dent. 2011;22(5):149-15. Keller DC and Cochrane B. Composition of Microorganisms in Periodontal Pockets. JOHD 2019:2(2):123-36. 
[12] Ibid. For more information on the chemistry and safety of hydrogen peroxide, see Marshall MV, Cancro LP, Fischman SL. Hydrogen Peroxide: A Review of Its Use in Dentistry. J Periodontol. 1995 Sept;66(9):786-96. 

[13] https://www.cdc.gov/oralhealth/conditions/periodontal-disease.html.

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