It has been known for centuries that dental health and systemic health are linked. However within the challenging environment of a hospital, oral care is still, quite often a low priority. Recent studies reveal that total bacterial count of dental plaque increases during hospitalisation[1] and the oral cavity of hospitalised patients can harbour high frequencies of bacterial respiratory pathogens.[2] As a result, this can lead to infections and hospital acquired pneumonia (HAP)².
 

As well as inadequate oral hygiene, the potential risks to oral disease and discomfort in hospitalised patients include a significant number of medications as well as artificial feeding and high-calorie food supplements used to maintain nutrition. In addition, the effects of nasal oxygen, mouth breathing, intermittent suction of the airway and the restriction of oral food and fluid all contribute to a decrease in saliva production and symptoms such as xerostomia.[3]
 

Another common problem for sick patients is the dry mouth and discomfort caused by constant open mouth posture that is required for intubation. For those undergoing surgery, there can also be further complications. A study involving 404 surgical patients under general anaesthesia facilitated by endotracheal intubation, revealed that 6.9% sustained various degrees of oral trauma including soft tissue laceration, tooth fracture, prosthesis damage, tooth avulsion, ecchymosis and numbness of tongue.[4] In addition, a recently published study on the oral health of 162 patients found an increase in plaque levels and deterioration of gingival health during just a short stay in hospital.[5]
 

If a patient that has recently been hospitalised attends the dental practice, practitioners may observe oral tissue and tooth trauma, high plaque levels, gingivitis and periodontal disease. As always, it is fundamentally important to reinforce oral health instructions and to treat any dental problems efficiently. If, for example, periodontal disease has developed, it is first necessary to remove and disrupt the plaque using root surface debridement (RSD). In cases with deep periodontal pockets it is usually necessary to implement an adjunctive therapy to inhibit further periodontopathic bacterial growth and allow the periodontium time to heal and stabilise. Some practitioners use antibiotics for this purpose, but, if the patient has recently been unwell and had antibiotics prescribed previously, the risks of resistance are greater and it is preferable to use an antimicrobial alternative.
 

Practitioners should therefore consider PerioChip^® – a wafer thin dental insert that is an effective, non-antibiotic alternative for treating periodontal pockets over 5mm. PerioChip^® is applied directly into the periodontal pocket and slowly releases chlorhexidine digluconate to eliminate 99% of bacteria over 7-10 days.^[6] Furthermore, the insert employs a controlled-release system and continues to provide an antibacterial effect to suppress bacterial growth for up to 11 weeks after placement.^[7]

As it seems that care for medical and dental problems are still less coordinated than we might expect, it is imperative to emphasise to patients that successful recovery after a period of ill health or hospitalisation is not just about the body but also their oral health.

PerioChip^® is available exclusively from Dexcel Dental, to order or for further information call 0800 013 2333 or email This email address is being protected from spambots. You need JavaScript enabled to view it.

In May 2015, the World Health Assembly endorsed a global action plan to tackle antimicrobial resistance, including antibiotic resistance, the most urgent drug resistant trend.

The World Health Organisation (WHO) defines antibiotic resistance as “resistance of a microorganism to an antimicrobial drug that was originally effective for treatment of infections caused by it.¹” They go on further to say it is a “natural phenomenon” and that the misuse and overuse of the medication accelerates this worldwide problem. The effect of this “ticking time bomb” is felt across the health of the global population and worldwide healthcare budgets.

The meeting in May created five strategic objectives to tackle the issue including increasing awareness and understanding, reducing the incidence of infection and developing the economic case for sustainable investment². A survey carried out by the WHO a month earlier found that of 133 participating countries, only 34 had a comprehensive national plan to fight resistance to antibiotics. It discussed how management of the situation was paramount but due to inadequate laboratory capacity, infrastructure and data management practice, trends and outbreaks were poorly detected and monitored. Importantly, many countries had no stringent guidelines on the prescription of antibiotics, which could result in overuse and misuse by prescribers.

Excess Expenditure

There is not only the effect this issue has on the health of the global population, but also the impact it has on a country’s economy. Drug-resistant infections could kill an extra 10 million people across the world every year by 2050 if they are not treated successfully. By this date they could also cost the world around $100 trillion in lost output². Health expenditure in most countries is rising steeply already and resistance to antibiotics is going to contribute significantly in the near future. Excess costs associated with the resistance are due to longer hospitalisation, delayed therapy, higher morbidity rates, the necessity for surgery and the need to use more expensive antibiotics³.

Jim O’Neill, an economist leading a review into antimicrobial resistance for the UK government, estimated that $37 billion is needed over the next 10 years to spur the pharmaceutical industry into developing innovations in this troublesome segment. He went on further to say that this was a “modest sum” compared to the cost of not doing anything. During the 1990’s, pharmaceutical companies withdrew from investing in this kind of research due to a high uncertainty around what the final market potential would be, and still the pipeline does not look particularly robust. Also, antibiotics work so fast and so well that they provide relatively weak returns for high investment. Companies prefer to channel their funds towards the treatment of chronic illnesses, such as diabetes, as drug treatment for this type of disease will be taken for longer periods of time; usually for the rest of the patient’s life.

Prevention Strategies

This naturally occurring threat is not going to be eradicated without preventative measures being implemented globally. In one research paper on the subject, Sipahi suggests that the following strategies should be followed:

-       Optimal use of existing antimicrobial agents

-       Where possible, use alternative therapies

-       Increase immunity

-       Educate healthcare professionals

-       Regulations and policies

-       Stringent infection control protocols³.

There are scientists working to develop new drugs able to combat bacteria that are resistant to antibiotics. One of the more recent discoveries reported in The Guardian earlier this year has been hailed as a “game changer” and is called teixobactin. It can kill a wide range of bacteria, including Methicillin-resistant Staphylococcus aureus (MRSA). Teixobactin works by blocking the capacity of resistant bacteria to build cell walls, therefore making it almost impossible for bacteria to develop resistance⁴. It is, of course, still early days.

Alternatives to Antibiotics

The alternative is to use drugs and therapies that do not contain antibiotics, yet are as effective in the results that they deliver. PerioChip® is a non-antibiotic solution and can therefore be used in the longer term. It is designed for use in conjunction with traditional treatment to suppress bacterial flora in periodontal pockets of 5mm or more. It contains 2.5 mg of Chlorhexidine Digluconate and is recommended for first line treatment of periodontal pocketing. Results from clinical studies show a pocket reduction of more than 2mm in almost three quarters of patients when placed every three months⁵.

Antibiotic resistance is a looming problem that all governments and healthcare professionals around the world need to take responsibility for. With alternatives to antibiotics available that can be used in dental treatment plans, dental practitioners need to carefully consider what they prescribe and ensure they are doing what they can.

To order PerioChip® or for further information Freephone 0800 013 2333 or email This email address is being protected from spambots. You need JavaScript enabled to view it.

Summary of product link;

http://www.old.health.gov.il/units/pharmacy/trufot/alonim/PerioChip_dr_1337488974840.pdf

Abbreviated Prescribing Information

PerioChip® 2.5mg Dental Insert (Chlorhexidine digluconate)

For full prescribing information, including side effects, precautions and contraindications, see Summary of Product Characteristics (SmPC).

Presentation: Dental insert: bullet shaped orange brown containing Chlorhexidine digluconate 2.5mg.

Indications: PerioChip® is an adjunctive antimicrobial treatment for moderate to severe chronic periodontal disease in adults with pocketing, combined with Root Surface Debridement (RSD). Not indicated in children and adolescents.

Dosage and Administration: One PerioChip® is inserted into a periodontal pocket with a probing pocket depth of ?5mm. Retreatment with PerioChip® following mechanical plaque removal at 3 month intervals may provide additional benefit if pocket depth remains ?5mm. For details see SmPC. Removal is unnecessary as PerioChip® biodegrades.

Contraindications: Hypersensitivity to Chlorhexidine digluconate or excipients.

Precautions: Allergic reactions have occurred but are rare.

Interactions: Avoid nystatin: antagonistic of Chlorhexidine. Chlorhexidine is incompatible with anionic agents present in some toothpastes and with dietary sucrose, but there is no significant impact on the efficacy of PerioChip®.

Undesirable effects: During the first few days after insertion, transient pain or discomfort of gums or teeth; redness and/or swelling of the gums.

Overdose: Not reported

Pregnancy/ Lactation: Controlled studies in pregnant women have not been conducted, so weigh expected benefits against possible foetal risks: caution in nursing mothers (see SmPC).

NHS list price: £207.20

Legal category: P, Product Licence Number: PL 14017/0035

MA holder: Full prescribing information is available on request from Dexcel Pharma Ltd, 7 Sopwith Way, Drayton Fields Industrial Estate, Daventry, Northants, NN11 8PB.

Adverse events should be reported. Reporting forms and information can be found at www.mhra.gov.uk/yellowcard.

Adverse events should also be reported to:

Dexcel Pharma Ltd on 01748 828784

1. Fact Sheet No194, WHO

2. http://amr-review.org

3. Sipahi OR. Economics of antibiotic resistance. Expert Rev Anti Infect Ther. 2008 Aug;6(4):523-39. doi: 10.1586/14787210.6.4.523.

4. The Guardian, 7^th January 2015

5. Soslkolne W.A et al. Probing depth changes following 2 years of periodontal maintenance therapy including adjunctive controlled-release of chlorhexidine. JOP 2003;74:420-427