Note to Readers: I just want you to know that this is written primarily to dentists and dental hygienists, however because it affects patient care I want patients to be able to read it as well. They should understand what this material can and cannot do in order to be able to give informed consent for its use.

Arestin® (Minocycline HCL 1mg Microspheres) is a locally delivered antibiotic that kills bacteria in a periodontal pocket without significant systemic absorption.

Arestin does not cure periodontal disease and I do not believe it makes enough of a difference during scaling and root planing to warrant the additional expense to the patient.

Where Arestin is very useful is in Periodontal Supportive Therapy (aka Recare or Periodontal Maintenance). Used correctly it can enable patients to not require periodontal surgery as frequently or at all.

How to Use Arestin in Periodontal Supportive Therapy (SPT)

  1. Always record probing depths at SPT appointments.
  2. Always note bleeding and probing depth together in the record.
  3. 5mm pockets that bleed should receive Arestin after light ultrasonic subgingival cleaning. Note in the patient’s record where Arestin was placed. You might circle the number or place “A” nearby.
  4. Repeat Arestin in the same site up to three SPT visits in a row.
  5. If the same site remains 5mm and bleeds three times in a row, discontinue Arestin. It is time to consider repeat scaling and root planning (the specific site only), periodontal surgery or referral to a periodontist.
  6. If  3 months later a site you previously placed Arestin in is still probing 5mm but is not bleeding then do not place Arestin (site does not need it).
  7. As long as you do not have to place Arestin in the same site three times in a row, you can continue to use it indefinitely (it is proving to be an effective management tool).
  8. If you have to place more than 5 Arestins at a visit, the cost/benefit ratio is out of whack. It may be time to repeat scaling and root planing. If the interval between scaling and root planings is years apart then this in my mind is fairly normal. If scaling and root planing was recently performed (within 12 months) then this is an indication that something more aggressive needs to be considered. Systemic antibiotics should not be necessary in routine SPT. If the whole thing is unclear, refer.

What about other pocket depths that bleed?

  1. 1mm to 3mm sites that bleed are usually accessible to brushing and flossing. A high bleeding index consisting primarily of shallow sites indicates either a patient compliance issue or possibly (rarely) a systemic issue (diabetes?). Besides, practically speaking, shallow pockets can’t hold the antibiotic in place long enough to be of any use.
  2. 4mm pockets receive only light ultrasonic cleaning (repeated root planing every appointment is discouraged because it results in significant loss of tooth structure and increased sensitivity over time).
  3. 6mm pockets may receive Arestin one time; however remember these are advanced sites. Usually periodontal surgery is the treatment of choice. This is because supporting pockets this deep in SPT usually results in further attachment (bone) loss.

If you have to use Arestin, the recall interval should always be 3 months (not 4 or 6).
The use of an antibiotic implies a problem that needs to be followed on a tight interval. Tightening intervals down to three months is the best first step when conditions are not adequately controlled. If the patient elects to not have a tighter interval, I suppose you can place Arestin, but I personally think this is silly. There is a compliance issue here, not a plaque issue.

Dental offices have my permission to use this material in patient handouts without citing me – just don’t publish it beyond your private use without permission. Thanks.

3 Responses

  1. Great post Benjamin. I especially like:
    1 taking of vitals( both arms for BP)
    2, your conservative approach re surgery
    3 your differentiation between active treatment and spt
    4. The importance of educating the patient esp re cute vs treatment vs maintenance
    5 your use of arresting ESP in consideration of cost to patient

    Just a few questions:
    1. How do you feel about perio laser tax (Periowave)
    2. Do you take pH tests at perio consultation
    3. Do you consider perio surgery an effective form of treatment esp with its esthetic consequences
    4. Would you consider saving a tooth with class 3 mobility, purulent exudate and 9 mm pocket
    5. Have you ever used ninocycline irrigation ( instead of Arestin)

    Thank you

    1. Thank you Dr. Hope for your comments and questions. Some of what you are asking I think will be coming out quite naturally in future posts, so do continue to read as I write. Specific questions about techniques without the time to provide a context as well as, in some cases, a disclaimer as to my competency to judge (because I recognize in some areas my opinion should have little weight) cause me to recommend you conduct a literature review to see whether or not certain techniques have sufficient scientific support. I will address a couple of questions I think I can give reasonable answers to.

      First, periodontal surgery is a broad topic and includes a number of regenerative techniques which fit well, and are actually designed for, the esthetic zone. You are very correct to point out that there are esthetic consequences which certain surgical methods will significantly and adversely impact, however I will always bring the discussion around to what does the patient want? If given the treatment options in addition to all of the risks, benefits and alternatives, with these alternative risks and benefits explained as well, what does the patient wish to do? Sometimes we discover that the patient wants something we would not personally choose. Then the question becomes, are you willing to give the patient what the patient wants, or if you do, will this be a deeper breech of trust? In other words, I recognize that sometimes patients want things that are detrimental to their health. I had a situation like this recently where I gave a poor prognosis to a maxillary second molar which means, as I will explain in a future post, that I can do every imaginable procedure to keep this tooth and I still expect it will not be present three years from now. The patient elected to not extract this tooth but to include treating it as part of a larger periodontal surgery. On follow-up visits she reported that the tooth was very sensitive and that she could not comfortably eat ice cream. So we reviewed the prognosis and her decision. She then elected to modify the ice cream and give it more time while understanding that there may come a time in the future when she might elect to have the tooth extracted. The point is I am giving her as much independence to make her own decisions as I possibly can. Which brings me to your next question.

      Class 3 mobility, in my book, indicates a tooth that is likely going to be lost in the very near future. The prognostic question you have to answer for yourself is whether this tooth has a poor prognosis or a hopeless prognosis. For example, if you have a 25mm root length (gigantic cuspid) and the mobility is due to a traumatic occlusion that can be corrected (I know these are unlikely, but not impossible) then it is not a hopeless prognosis. But if you put it in the poor prognosis category, you are not telling the patient everything is rosy. We don’t want to get ourselves in situations where the patient can come back to say that we, in any way, promised a particular outcome to a procedure, especially one involving an extremely compromised tooth. When a tooth, in my profession opinion, has become hopeless, then what I am saying to the patient is that the tooth must be removed ASAP. For the patient to go against my advice at this point is for the patient to elect to seek treatment elsewhere because for me to retain a tooth I believe to be hopeless simply because this is what the patient wants, is for me to be committing malpractice. I therefore must stand my ground, still giving the patient the choice between extraction and seeking the services of another provider. Should I “force” the patient to do what I want, I am now running the risk of committing some form of assault. “That doctor extracted my perfectly good tooth against my wishes,” is not a legal challenge I want to try and defend.

  2. How long is Arestin effective? I was told it works in the pocket for a 6 week period of time, but should not be disturbed for 10 days.

Leave a Reply

Your email address will not be published. Required fields are marked *