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Frequently Asked Questions
When should antibiotics be taken when starting SRP?
Antibiotics should be started on the same day as scaling and root planing (SRP).
Per Magda Feres’ paper ‘Systemic antibiotics in the treatment of periodontitis’, to have the best and most sustainable results with SRP a “…rapid and massive reduction of the total bacterial levels, especially of the strictly anaerobic pathogens…” is needed to allow the best possible recolonization of commensal species.
We prescribe antibiotics on the day of scaling because that’s when the infection is most active. At this stage, elevated levels of gingival crevicular fluid and increased capillary permeability help deliver a higher concentration of the antibiotic to the subgingival area, improving local uptake and effectiveness.
According to Feres, another reason we give antibiotics at the start of periodontal treatment is to prevent harmful bacteria—like certain tissue-damaging types—from taking advantage of the disruption caused by scaling and root planing. By keeping inflammation down during healing, we make it harder for these bacteria to grow back. It’s a cycle that is often see in microbiology: the bacteria shape the environment, and the environment affects which bacteria can grow. By altering the periodontal environment to one that is more favorable to commensal bacteria, we can suppress, alter, or even eliminate the pathogenic species more effectively.
In what order do you recommend use of CariFree Treatment Rinse (formerly CTx4), the Waterpik with bleach additive, and brushing? Also, would you substitute use of Ctx4 in the Waterpik instead of bleach?
The ideal ‘order of operations’ for a patient while doing their home care is as follows:
- Interproximal Care: Waterpik with bleach, rinse with CariFree Treatment Rinse (formerly CTx4) for 1 minute
- Mouthrinse, if applicable: Recommended to use for 1 minute. Generally stable patients do not need a mouthrinse within their normal homecare routine.
- Brush: Brush with the toothpaste of choice for 2 minutes with the patient expectorating the residual toothpaste out of their mouth, but not rinsing, to retain the toothpaste’s active ingredient in their mouth.
We do not recommend use of CariFree rinse in the Waterpik. The diluation of the CariFree Treatment Rinse was formulated to combine both the ‘A’ and ‘B’ rinse. to result in a 0.2% sodium hypochlorite mixture. Further dilution in the Waterpik reservoir can render the rinse ineffective.
A handy informational is available in our Wellness Dentistry Network library that is a great handout to patients that help them remember this key order of operations for optimal results.
What is your protocol if bacteria are still above threshold after a retest?
If bacterial levels remain high after retesting without significant alteration, several factors should be considered:
- Genetic predisposition: A PST genetic test from Interleukin Genetics/OralDNA Labs may provide insights.
- Evaluation of bleeding on probing (BOP) sites: Investigate if any are linked to defective restorations or recurrent caries.
- Assessment of plaque control: Verify patient compliance with the recommended Daily Disease Management Regimen. Ask open-ended questions to the patient what their homecare routine is to allow them to guide the conversation and use motivational interviewing techniques to assess their compliance.
- Possible yeast or viral component: Assess if yeast or viruses may contribute to the bacterial persistence. For yeast, issues like chronic sinusitis, GI disturbances, or frequent yeast infections may indicate that this microbe is present and a salivary test may be warranted. For viruses, a frequent history of cold sores may indicate that there is a viral component at play. Periodontal disease is a polymicrobial infection based upon interkingdom assemblages, which makes it imperative to assess all microbiological entities as potential contributors or intensifiers.
- Transmissability: Investigate if the patient’s spouse or family members have periodontal disease. Many times spouses or family members have similar microbial make-ups making reinfection possible and a treatment more difficult.
- Assessment of risk factors: Reexamine the modifiable and nonmodifiable risk factors that patient has. Determine if the patient smokes, as it can impact periodontal health. Assess if the patient has diabetes or is prediabetic. If the patient is diabetic, asses if it is controlled, including monitoring their A1c levels.
- Antibiotic regimen compliance: Confirm if the patient adhered to the prescribed antibiotic regimen during active therapy.
After working through these questions, adjust the treatment plan as needed. Often, this means doing a ‘mini-disinfection’—a follow-up dose of antibiotics along with another round of repetitive biofilm therapy. Patients should stay on their home care routine unless advised otherwise. Keeping them on a consistent 6–8 week recare schedule is key to managing dysbiosis. If things look stable at their 6-week follow-up, it’s a good time to retest and confirm progress.
Our protocol continues to evolve over years of experience and emerging evidence-based research to enhance patient outcomes. For further details, consult the Implementation Toolkit on WDN.
What pastes are available without Sodium Lauryl Sulfate (SLS)?
Numerous over-the-counter toothpastes are available without SLS for patients who prefer to avoid it for holistic or reactivity reasons.
However, it’s essential to consider the abrasiveness of these toothpastes, as we always aim to recommend low-abrasivity options. For a detailed list of toothpaste abrasivity, please consult the Abrasivity Index of Common Toothpastes. Common over-the-counter toothpastes that has low-abrasivity and is SLS-free is Sensodyne Pronamel or Sensodyne Fresh Mint Toothpaste. One high-fluoride toothpaste we recommend is Fluoridex® Sensitivity Relief SLS-Free Toothpaste or CariFree® Fluoride Free Gel with Nano-HA.
When and to who do you administer the salivary diagnostic test?
First, it’s essential for your hygiene team to agree on clear criteria for identifying active disease and when salivary diagnostics are appropriate.
In our office, we use four or more line bleeding sites as a sign of active disease. We then determine if bone loss is present. Even patients with gingivitis (no bone loss) may benefit from testing, though it may affect CDT coding for future treatment (e.g., D4346 vs D4341/D4342). If a patient meets our criteria, we go over their clinical findings, discuss the potential systemic impact of their oral inflammation, explain the nature of their microbiological imbalance, and give them an educational packet to review.
For generally healthy patients with early signs of gingivitis or perio, we may either begin with testing or recommend changes in homecare—such as a Waterpik with diluted bleach, twice-daily antimicrobial rinses, and switching to a power toothbrush with specific paste. Re-evaluation happens within 6 weeks to 3 months. If inflammation persists, we strongly recommend testing.
For those with moderate-to-severe disease (Stage II or greater), testing is typically advised if they have 4 or more spots of bleeding unless they prefer to get a cleaning right away, in which case we defer the testing for 6 weeks. We avoid testing if they’ve taken antibiotics in the past 6 weeks.
Testing may also be appropriate for patients with systemic conditions linked to periodontitis (e.g., uncontrolled diabetes, GI cancers, or immune compromised), patients who exhibit signs of Candida imbalance like altered taste or chronic sinusitis, or patients that report frequent viral expression such as frequent cold sores.
All testing is based on clinical indicators, and patients are always given the choice to decline salivary diagnostics.
When CAL is significant in the presence of inflammation but without pocketing noted on perio charting, should pt move into 4346 or 4341(SRP)?
Clinical Attachment Loss (CAL) is a key marker for assessing periodontal health. It measures the distance from the cementoenamel junction (CEJ) to the base of the sulcus or pocket, helping to show how much of the periodontium is supporting the dentition. CAL and assessing radiographic bone loss are considered the gold standards for evaluating the severity of periodontal disease, as it includes recession, pocket formation, and bone loss.
An increase in CAL usually indicates disease progression—even without deep pockets. When this happens, both the periodontal chart and radiographs are essential for an accurate diagnosis. Radiographs help determine the extent and location of bone loss, which is critical for proper staging and grading. If no bone loss is seen, recession may be due to anatomical factors like a tight frenum or past orthodontics.
If there’s significant CAL but no deep pockets, scaling and root planing (SRP) might still be needed if bone loss is present on the radiographs.
Treatment codes based on findings:
- 4346 – No bone loss but generalized inflammation (>30% of the dentition): Generalized Gingivitis
- 4341 – Bone loss with SRP needed on 4+ teeth in a quadrant: Periodontitis (Stage/Grade)
- 4342 – Bone loss with SRP needed on 1–3 teeth in a quadrant: Periodontitis (Stage/Grade)
- 4910 – After SRP, patients move to Periodontal Maintenance
If CAL is present without deep pockets, check radiographs. Bone loss = SRP (4341/4342); no bone loss = 4346.
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The Wellness Dentistry Network (WDN) is a collaborative community of forward-thinking dental professionals committed to transforming the way dentistry supports whole-body health. Founded by Dr. Doug Thompson, WDN is built on the belief that personalized, preventive, and evidence-based care is the future of dental medicine. By focusing on the links between oral conditions and systemic health, WDN equips clinicians to address the root causes of disease—not just the symptoms.
What sets WDN apart is its balanced approach: advancing patient care while supporting the business of dentistry. Through tested protocols and processes, members learn how to integrate risk-based care that improves clinical outcomes and strengthens the health of the practice itself. It’s not about selling more services—it’s about delivering more meaningful care and making an impact on your patient’s whole health.
As a member, you’ll gain access to a deep library of tools, continuing education, and clinical resources designed to keep your team at the forefront of wellness dentistry focused on the oral-systemic link. You’ll be better equipped to meet the growing demand for comprehensive, individualized care—boosting patient trust, retention, and long-term practice success.
This is more than a network.
It’s a movement changing the paradigm of dentistry to one that is smarter, healthier, and more impactful—one grounded in science, elevated by collaboration, and driven by purpose.
