Arrestin and its use

[rocknightmare]

i saw a thread that just got closed because of request for medical advice..

but anyways this topic will be more general. At my school we only use arrestin after sc/rp at intial therapy and then seeing how deep the pockets are.. if they are generalized deep pockets we recommend open flap debridement. and arrestin is only recommended for locazlied areas. what do you all do?

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[charlestweed]

i saw a thread that just got closed because of request for medical advice..

but anyways this topic will be more general. At my school we only use arrestin after sc/rp at intial therapy and then seeing how deep the pockets are.. if they are generalized deep pockets we recommend open flap debridement. and arrestin is only recommended for locazlied areas. what do you all do?

Sc/rp with or without Arestin (and other drugs ie. Atridox, Actisite etc.) yield similar clinical result: some attachment gain and some reduction of perio pocket. Most perio faculty and perio resident at USC perio department believe that it is “unethical” to let the public to believe that this drug can help treat perio dz w/o the need for periodontal surgery.

You have to understand that bacteria don’t just form complex matrices on the root/crown surfaces and by doing sc/rp the perio problem is gone. The bacterial matrices also get incorporated deeply into the root cementum. So by doing flap surgery, periodontists can effectively eliminate complex bacterial matrices by “shaving off” the infected cementum layer, eliminate interproximal bony crater, and remove excessive gingival tissue to establish normal pocket depth. Arestin may be used in initial therapy (with very minimal benefit and cost a lot of money) and does nothing to help restore periodontal anatomy damaged by periodontal disease.

 

[servitup]

I commented on the last thread. I would use arrestin in a patient with refractory localized pocketing less than 6 mm after initial SC/RP if I was a GP. If pocketing after initial therapy was generalized or pockets were deep, I would go straight to surgery.

 

[red88m]

I use Arestin in practice after SRP or at subsequent perio maintenance appointments. As with SRP you can get long junctional attachment with Arestin and this may postpone the need for perio surg. I find it useful for direct buccal or direct lingual pockets of less than about 7mm, depending on the situation, AFTER SRP. We generally do SRP first, and at the re-eval place the Arestin if needed. It's definitely a localized treatment- could do as many as maybe 3 or 4 sites per quad. And there is a time when the bone loss is so severe that Arestin really would be a waste of money.
If it's maintainable non-surgically, why not use it? Even if you have to re-administer it in a year or two, it still saves the patient from surgery.
If we could give a "Change in Habits" pill it would be better. (Usually)

 

[charlestweed]

If it's maintainable non-surgically, why not use it? Even if you have to re-administer it in a year or two, it still saves the patient from surgery.

It can only be maintainable if the pocket depth is normal ie 2-3mm deep.

 

[red88m]

4mm is okay, I think, without bleeding. And sometimes a 5mm on the ML of #3. As long as there is no bleeding and it's nice and tight.
Do you disagree, Dr.?

 

[Ebull]

4mm is okay, I think, without bleeding. And sometimes a 5mm on the ML of #3. As long as there is no bleeding and it's nice and tight.
Do you disagree, Dr.?

Why only a 5mm on the ML of #3, what significance does that molar have above others that it makes the drug more efficacious.

 

[red88m]

Why only a 5mm on the ML of #3, what significance does that molar have above others that it makes the drug more efficacious.

It's not that the drug is more efficacious there, it's that I find the maxillary first molars do pretty well with a 5mm "pocket" ON THE ML that is not inflamed. I don't remember the details of my tooth morphology (which was not extensive in the first place) but I think it has something to do with the shape of the max. firsts or just the alignment of the teeth in that area. Maybe the spacing between the palatal and MB roots? Shape of the crown? I dunno- you morphology students tell me. This obviously isn't true for every patient, and depends on the case.
But it doesn't have anything to do with the drug. I'm basically saying that you can have a maintainable 4 or 5mm pocket if there is no active inflamation, which is often what you get if you place Arestin in a 6+mm pocket. (In my experience.)

BTW, I'm not trying to play dentist or undermine any instruction you had in dental school about all this- I'm just telling you guys what I see work in practice and how I would handle it. Hope I don't step on any toes. 😳

 

[charlestweed]

It is still very difficult for pt to maintain deep pockets like these; it is also very difficult for most dentists to scale teeth w/ deep pockets even w/ the right scaling instruments. The ideal treatment is to do surgery to get the teeth back to a maintainable state…..of course, this would mean pain and ugly looking teeth w/ exposed root surface. I personally think surgical approach is more predictable and cost effective than multiple visits of expensive Sc/RP w/ Arestin.

If pt declines surgery, then he/she should be correctly informed that Sc/RP is an alternative tx but it is not a correct tx of choice.

 

[backaction]

arrestin is garbage. so is perichip, atridox, etc. most of the current literature on these products show no support for their use. a 0.3? mm reduction in probe depth is a worthless claim to fame. statistically a marginal gain, but clinically nothing. all these local delivery systems only have short term effects and then any gain is over. you can't bring in patients every visit to put $120 of this around a single tooth and do this over and over agin and then have it break down. It's not fair to the patient and a weak treatment.

to eliminate the pocket, the anatomy of the pocket must change...so it needs to be removed to a shallower form in hopes that this new anatomy will be able to be maintanined by the patient. most of the reduction in depth is not from reduction in marginal inflammation either, it's from resecting the tissue. of course you get long ugly teeth when this happens. teeth with single roots can be maintained with 6 mm depths with good homecare, multi rooted teeth cannot. maintenance means good home care and frequent dental visits. Patients maintained on a 3-4 month regimen can usually do ok even in the presence of bad hygiene. You can read stuff by ramjford and slots on this topic.

Membranes: Personally, don't thing guided tissue regeneration is very predictable either. It's the blood clot that is key, not the membrane. The membrane is the flap of tissue. I don't beleive in epithelial exclusion. The blood clot is how things work. You think a membrane is going to stop any cells from moving around. I don't buy it. Maybe resorbable ones in very select cases. cleaning out a perio defect well will get some bone with good home care. It doesn't matter what you put into the defect (bio oss collagen, bio oss, FDBA, DFDBA). I personally like bio oss collagen because it's more rigid with the collagen and helps stabilize things so a nice blood clot will form. You might get a little bone on the bottom with fibrous tissue along the root, but often times it's enough to prevent the probe from penetrating. Some studies do show new cementum, bone etc., but clinically most of the time curetting out a defect really well will be equivalent to grafting etc., unless you are a magician. DFDBA has no application really. Decalifying releasing BMP's is bogus. DFDBA is nothing. I don't think autogenous shavings remain viable long enough either. The cells are dead, but it's at least a filler that will resorb and allow real native bone to fill in. Use autogenous whenever possible, otherwise don't use anything, especially if an implant is gonna be next to the stuff. I can't comment on the viability of blocks and how "alive" they are.

Now let's talk about emdogain. This too is a worthless product. No support for this product. Go to most other countries and they will laugh at anyone using this stuff. It's a marketing gimmick. Some like to soak alloderm grafts in it or squirt it around a soft tissue graft and claim that the healing is accelerated, but I don't beleive there is any clinical evidence that it's doing anything here. Others use it in hopes of miracle regeneration. Don't beleive the hype.

Socket grafting: another thing that puts big money in the pocket of the surgeon. Mixed support for this stuff. Good literature shows that it doesn't matter what you put into a socket. It's gonna heal how it's gonna heal regardless of what goes into it. Why put in allgraft garbage when you can just let the socket heal and regenerate native bone on it's own. If the buccal wall fractures or is thin it may resorb, but can be grafted later at time of implant placement if need be. Why would anyone want allograft next to their implant. If I had an implant I woulnd't want that crap next to mine. How can you tell if the implant is osseointegrated if it's surrounding this stuff.

PRP: Another mixed bag. Personally don't think it does anything. If it does anything it's only for soft tissue. I don't think it has much effect on bone grafting. I don't know enough about PRP than other products, however. Good articles show no to weak support for this stuff.

In terms of predictability: Resective > GBR > GTR

and lastly, for crown lengthening: place the margin into the attachment on straight buccals and linguals in non aesthetic zones. nature will do the crown lenghening and you won't get much in the way of negative architecture.---i'm not talking about aggregiously deep situations (like at bone level), but cases where you will be slightly into the attachement....this idea won't work interproximally, however.

any other opinions/views on this stuff or anything else perio related?

 

[red88m]

Sounds like a periodontist here? I was wondering what you guys are using in your practice for AAP classifications- the old system or the new one?
As for the Arestin again, I've seen up to 2 mm improvement in PD- but it has it's place in localized perio with slight bone loss. We only charge $50 per site and don't apply it at every visit. Only if there is active inflammation in that site again and it hasn't progressed. I can think of 4 periodontists who like Arestin and use it in practice- one I think teaches at VCU- or used to a couple years ago.
Perio chip IS garbage.

 

[johntara04]

arrestin is garbage. so is perichip, atridox, etc. most of the current literature on these products show no support for their use. a 0.3? mm reduction in probe depth is a worthless claim to fame. statistically a marginal gain, but clinically nothing. all these local delivery systems only have short term effects and then any gain is over. you can't bring in patients every visit to put $120 of this around a single tooth and do this over and over agin and then have it break down. It's not fair to the patient and a weak treatment.

I don't like this argument at all. If this is how you feel, how do you justify doing a crown, endo, or any restorative procedure? In dentistry, you can't cure what the patient isn't willing to do, and no treatment you do (except extraction) is a cure all. Every procedure you do will break down and need to be redone/or re-treatment planned. If the patient is trying to stop the progression of their perio, then Arestin every time they come in is perfectly acceptable treatment. According to your argument, giving a patient fluoride treatment at every hygiene appointment is also 'not fair to the patient and a weak treatment.'

It all comes down to you as doctor doing what is best for the patient; meaning the treatment that gives the patient the best chance for success based on the patient's health and ability to maintain their health. Some patients can be on Arestin for years and do just fine; others would be better to just pull the tooth and do some sort of prostho alt. treatment. I just don't believe you can make a blanket statement like the one I have bolded.

 

[charlestweed]

If the patient is trying to stop the progression of their perio, then Arestin every time they come in is perfectly acceptable treatment. According to your argument, giving a patient fluoride treatment at every hygiene appointment is also 'not fair to the patient and a weak treatment.'

I respectfully disagree w/ you on this point. I believe that sc/rp alone can slow down the progress of perio dz. But to stop the progress, you will need to have healthy pockets + 3-4 month perio maintenance + good pt home care. I just can't see how a chronic disease like periodontitis can be sucessfully treated w/ a single (or multiple)application of Arestin.

 

[backaction]

That's the problem with perio...it unlike endo relies on the patient for its success for the most part. How can you justify using these local delivery systems. what is there, 4 or 6 sites per tooth at like $60 a site? that's like a few hundred dollars every few months for a tooth or two. They are better off longterm by having the anatomy of the pocket changed. It's more predictable and in the longrun a lot cheaper than longterm arrestin. i just think it's a tremendous burden on a patient to have to get this stuff placed into their pockets as a form of maintanence in hopes that it might prevent breakdown. What happens when they stop using arresting and breakdown or if they invest money over months to years and it doesn't work? tons of money invested into something with a poor result. i'd rather just do a little flap procedure and have the patient come in for maintenance prophys every few months. Your philosophy may work for you, I just don't agree with it.

anyone have anything to say about EMD

 

[johntara04]

I respectfully disagree w/ you on this point. I believe that sc/rp alone can slow down the progress of perio dz. But to stop the progress, you will need to have healthy pockets + 3-4 month perio maintenance + good pt home care. I just can’t see how a chronic disease like periodontitis can be sucessfully treated w/ a single (or multiple)application of Arestin.

I really think you missed the point. Let me put it this way:

If the patient is trying to stop the progression of their perio, then Arestin every time they come in is perfectly acceptable treatment to supplement/aide/help the rest of their treatment plan. According to your argument, giving a patient fluoride treatment at every hygiene appointment is also 'not fair to the patient and a weak treatment.'

Just as sc/rp can help to slow down perio, so can arestin. When used properly, it is effective and does do good for the patient's teeth. Whether or not it is the best treatment for a particular patient depends on a lot of factors, but you cannot throw out a blanket statement saying arestin is always bad. Heck, crowns can definitely be used improperly as can simple restorative.

I forget that you have to spell out every last tit and tat on here. 🙂

 

[johntara04]

That's the problem with perio...it unlike endo relies on the patient for its success for the most part. How can you justify using these local delivery systems. what is there, 4 or 6 sites per tooth at like $60 a site? that's like a few hundred dollars every few months for a tooth or two. They are better off longterm by having the anatomy of the pocket changed. It's more predictable and in the longrun a lot cheaper than longterm arrestin. i just think it's a tremendous burden on a patient to have to get this stuff placed into their pockets as a form of maintanence in hopes that it might prevent breakdown. What happens when they stop using arresting and breakdown or if they invest money over months to years and it doesn't work? tons of money invested into something with a poor result. i'd rather just do a little flap procedure and have the patient come in for maintenance prophys every few months. Your philosophy may work for you, I just don't agree with it.

anyone have anything to say about EMD

You make good points that are all valid. That is why you must give full disclosure to your patient and not promise them something you can't deliver. Arestin is not for everybody, but it is a useful tool that can be of benefit to a lot of people.

As much as changing the pocket may be effective, it is not for everybody. There are a lot of people out there that would do anything (including paying thousands of dollars a year to you) to not have to do that. There are a lot of psychological and cosmetic reasons to put off having to do that, and for a lot of people, coming in every three months for a perio maintenance that includes arestin is a much more desirable option than a pocket reduction surgery. In some cases, your preferred treatment is the best option. But there are other cases where a patient would leave you if they found out they could pay a lot of money to keep their gums and a more "desirable" smile. That is why we need to treat every patient as an individual and find out what treatment options are best for them. There is no cure-all in medicine. Every case is different, and every case has the opportunity to multiple options on treating. We need to find the best one overall.

Plus, the only real way to stop perio is full mouth extractions, so unless the patient wants that, every treatment has its own pros and cons. It is our job to find the treatment that gives our patients the best chance for success. Its why we get the big bucks. 😀

 

[red88m]

You make good points that are all valid. That is why you must give full disclosure to your patient and not promise them something you can't deliver. Arestin is not for everybody, but it is a useful tool that can be of benefit to a lot of people.

As much as changing the pocket may be effective, it is not for everybody. There are a lot of people out there that would do anything (including paying thousands of dollars a year to you) to not have to do that. There are a lot of psychological and cosmetic reasons to put off having to do that, and for a lot of people, coming in every three months for a perio maintenance that includes arestin is a much more desirable option than a pocket reduction surgery. In some cases, your preferred treatment is the best option. But there are other cases where a patient would leave you if they found out they could pay a lot of money to keep their gums and a more "desirable" smile. That is why we need to treat every patient as an individual and find out what treatment options are best for them. There is no cure-all in medicine. Every case is different, and every case has the opportunity to multiple options on treating. We need to find the best one overall.

Plus, the only real way to stop perio is full mouth extractions, so unless the patient wants that, every treatment has its own pros and cons. It is our job to find the treatment that gives our patients the best chance for success. Its why we get the big bucks. 😀