Hello doctor, I am a 62-year-old female with a history of chronic periodontal disease, particularly involving a pocket between teeth #7 and #8, which is associated with some bone loss and becomes infected every few months. I take fastidious care of my teeth and gums, including flossing, using a proxy brush and water pick at least two to three times a day, which helps to keep the periodontal inflammation under control. But, every few months, I have a flare-up of redness, swelling and sometimes bleeding with pus in this area in spite of diligent care. During times of flare-ups, I use hydrogen peroxide in water pick, good germs designed specifically for gums and Peridex following cleaning. Sometimes, this regimen works well and resolves the infection. Other times, it does not, and I have to resort to having the pocket cleaned out using Cavitron ultrasonic and treated with Arestin (Minocycline) 0.1 % antibiotic gel by my periodontist. I started having symptoms of pressure and mild pain in and around tooth #8 about two days ago. I guess these symptoms to be the beginning of infection. There is no redness, swelling or abscess of the gum at this point. I do not want to lose the tooth, so I am very concerned to treat this infection early but, I am concerned about using the antibiotic gel too much and creating a resistant superbug. The X-ray consistently shows a large pocket between #7 and #8 with some bone loss. I am unable to post the X-ray here. The tooth is intact. The pocket was treated using Arestin (Minocycline) 0.1 % antibiotic by placing it in the pocket on several occasions since five years with in-between gaps of one to two years. Otherwise, it is managed with my daily hygiene regimen, regular hygienist cleanings every two months, including using Cavitron ultrasonic to clean out the pocket, and, use of Hydrogen peroxide, good germs, and, Peridex during flares. My questions for you are:  I am concerned about developing a superbug in my mouth (i.e., antibiotic-resistance) from frequent use of the Arestin antibiotic gel in that pocket. How dangerous would that be? What is the likelihood such a resistant bacteria is created? Is there anything you can do about it? In the situation where the gum gets infected to the degree I need to get an antibiotic gel put on by the periodontist, would oral antibiotics be preferable or more effective? How effective would oral antibiotics be for this? Would a root canal help to reduce the problem of ongoing, repeated infections in regards to the gum disease? Or would that be irrelevant to the gum disease?
Hi. The antibiotic resistance is not a big issue as such, but I would suggest to not apply antibiotic gel more than two weeks with one or two months gap in between. Using warm salt water gargle twice a day is more than enough for good hygiene of gums. Root canal treatment will not help much in resolving gum infection as such but will stop any toothache or sensitivity you might be having in the concerned tooth. The X-ray which you have attached suggests a ceramic bridge which is placed to replace a missing tooth (attachment removed to protect patient identity), but root canal treatment has not been done for the supporting two teeth. It is better to get them root canal treated to prevent any mobility of those teeth and to get added strength by ankylosis of the roots to the bone. And if the gum infection is around that bridge then it is highly recommended to get them root canal treated for more strength. Chlorhexidine antibiotic gel or even Metrogyl (Metronidazole), if available there, is good enough for a local application. Continue with mild Hydrogen peroxide gargle or salt water (I recommend) and scaling of your teeth and gums once in six months. For more information consult a periodontist online -->