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Profile in Oral Health By Trisha E. O’Hehir, RDH, BS, Editorial Director, Hygienetown Magazine

More by this author (282)
Exciting innovations in periodontal therapy challenge our traditional approaches to treatment and prevention. In this article, Hygienetown Magazine interviewed four companies that are bringing some of the newest periodontal innovations to the forefront – from oral hygiene aerobics and waterbeds, to patient commitments we never expected, plus lasers and regenerative perioscopy. All of these treatment innovations require additional training and/or certification to ensure that your patients receive the highest quality of care. It’s an exciting time to be a dental hygienist!


AirPerio

AirPerio is a three-part method that focuses on the anaerobic bacteria with an aerobic approach. The first step is bacterial DNA testing; second, non-surgical aerobic treatment called BOST; and third, daily aerobic oral hygiene by the patient. During treatment, a French-made, heated waterbed with a dental headrest provides a warm, flat surface that is comfortable support for long appointments. Dr. William Hoisington, founder of AirPerio, is a graduate of the University of Washington, did post-graduate periodontics study in France, has clinical practices in Monaco and Washington state, and teaches at the University of Florida and the University of Nice, France.

What will the DNA testing tell you?

Hoisington: DNA testing will tell us which bacteria from a list of 11 are prevalent in the periodontal pocket. Many can be eradicated with non-surgical therapy, but two aggressive, invasive species might require systemic antibiotics, Actinobacillus actinomycetemcomitans (Aa) and Porphyromonas gingivalis (Pg). These two are not part of normal flora and can invade to areas inaccessible to mechanical removal. Each strain of bacteria has a unique genetic fingerprint that can be identified. Subgingival bacterial samples are collected on paper points that are placed in the pocket for 15 seconds, removed, inserted into the carrier package and sent to the lab.

Why do you call your non-surgical therapy BOST?

Hoisington: BOST is an acronym for the Bone One Session Treatment. This initial therapy is completed in one session, which can last four to five hours. I prefer to complete the treatment in one day to allow the immune system to focus completely on healing rather than leaving the body to continue fighting the infection in the untreated sections while also focusing on healing the treated section. The BOST treatment uses a stretch flap technique that protects the tissue and the bone. Periodontally infected tissue loses its fibrous nature and becomes spongy, which allows me to stretch it out and provide access to the base of the pocket and bone surface without cutting the tissue. This keeps the blood supply to the bone intact, avoids bone necrosis, provides good access for removal of bacterial contaminants, and access to the infected bone. Using a brand new curette, I instrument the crest of the bone, stimulating stem cell expression from the periodontal ligament. The healing process fills the pockets in from the bottom and stimulates new bone and connective tissue formation. The use of the aerobic oral hygiene acts like a membrane to keep the epithelium away from the roots.

Tell me more about the aerobic oral hygiene your patients do at home.

Hoisington: Brushing and flossing just don’t reach all the way to the attachments, so I have my patients use a Perio-Aid in addition with specifically designed and treated green tips called aeros (Figures 1 and 2). The idea is to reduce biofilm and aerate the subgingival areas all the way to the attachment and in the grooves and furcations. The patients are instructed to listen for the squeaky clean surface, look that no blood is on the aero tip and that the attachment feels firm.

For more information on AirPerio visit: www.airperio.com.



Perio Protect

This approach delivers medications subgingivally with special trays. These custom trays are designed with a special seal and supporting extension around the periphery of the teeth. This gently guides medication interproximally and subgingivally and maintains it in the pocket. When the patient bites on the tray, it serves as a “mechanical pump” to move the medications to the source of the infection. Dr. Duane Keller, inventor of Perio Protect, graduated from Washington University in St. Louis, Misouri, and has had a private practice in St. Louis for 30 years. He has published more than 35 peer reviewed articles dealing with chronic pain and periodontal disease, is a consultant to many universities, and has received numerous awards throughout his career.

The Perio Protect Tray system you designed is an innovative way for patients to control periodontitis at home. How did you come up with this concept?

Keller: I was trying to help my mom. She had one quadrant of periodontal surgery and asked me to find a new way to treat her gums as the surgery was very painful – her teeth were longer and were very sensitive to cold. After many steps I developed a special tray that was able to overcome crevicular flow and deliver medications to the source of the infection (Figure 3). Dr. Bill Costerton, the director of the Center for Biofilms at USC Dental School and Dr. Christoph Schaudinn demonstrated it was possible to re-crystallize tetracycline in maxillary 6mm pockets using the Perio Tray. The delivery of medication into 7mm pockets was also done to the satisfaction of the FDA, which cleared the tray as a medical device to treat periodontal disease.


I’ve read the research using the Perio Trays and was impressed with the microscopic changes in bacteria in the pockets following treatment and the reductions in pocket depths, bleeding and CRP levels. How are patients instructed to use the Perio Trays?

Keller: The medications are prescribed by the dentist and worn in accordance with the most severe infection for 10 to 15 minutes per application for one week, during which time 95 percent of the bacteria are killed. The wearing frequency is then decreased in accordance with the healing that has occurred and 98 percent of the bacteria are killed by two weeks. By 17 days, 99.98 percent of the bacteria are killed. Research has also shown that tissue return to normal after 14 days of treatment. Once the disease is under control, patients wear the trays as a part of their long-term homecare program. Only a few cocci and Actinomyces type of bacteria are found to grow when using the Perio Tray regularly.

According to the research, people only spend 38 seconds brushing and rarely floss their teeth. Is compliance with a procedure that takes 30 minutes each day a problem?

Keller: Actually the procedure takes about 10 minutes and you’d be surprised to learn that patient compliance is very high. They can do other things while wearing the trays, like take a shower. The patient’s teeth feel clean like they are just getting out of the hygienist’s chair because the medication breaks down the protein coating the teeth. This is a clean feeling that everyone notices. Patients are impressed at how simple and easy the Perio Protect Trays are to use and they’re very happy with the results, so compliance is high.

Medical research has shown anaerobic gram-negative bacteria are associated with cardiovascular problems, Type II diabetes, pre-term and low birth weight babies and Alzheimer’s disease. Does the Perio Protect method affect these periopathogens?

Keller: The most virulent bacteria you mention are the first bacteria killed with the Perio Protect System. Patients are becoming increasingly aware of the oral/systemic associations and want to do whatever they can to improve their chance of good health. That is another reason for the excellent compliance.

For more information on Perio Protect visit: www.perioprotect.com.



Regenerative Periodontal Endoscopy (RPE)

RPE involves a periodontal endoscope, medication to control inflammation and a bone regenerating substance to enhance non-surgical periodontal therapy to achieve periodontal health and new bone regeneration. Judy Carroll, owner of PerioPeak Innovations, has been a dental hygienist and periodontal therapist in the state of Washington for the past 17 years, focusing the last seven years on an innovative use of the dental endoscope to treat periodontal disease and regenerate bone. She teaches her pioneering RPE approach to groups and individuals, dentists and hygienists, and treats patients from the across the country who seek out her innovative approach to conservative periodontal therapy.

Judy, you’ve been very active on www.hygienetown.com and posted several of your amazing cases of bone regeneration that we’ve included in the magazine over the past year. You’ve really taken Perioscopy to the next level with your approach to bone regeneration. How do you get these incredible results?

Carroll: As with many innovations, it didn’t happen overnight. Thousands of hours of work over the past seven years working with a Perioscope have gone into developing RPE; a predictable approach for effectively treating periodontal disease and achieving bone regeneration. The RPE procedure I provide patients involves several steps. First, patients begin taking subantimicrocial dose doxycycline two weeks prior to the endoscopy procedure, to control the inflammatory response and reduce the bleeding. This allows for better visibility in the pocket. Second, I use my Perioscope (Figure 6) which magnifies to 48X the subgingival area I’m treating in order to remove all the bacterial deposits. The third step is a very specific technique, which delivers a substance that stimulates bone regeneration (Figures 4 and 5).

This certainly is an innovative alternative to periodontal surgery for some cases. How can other hygienists learn this technique?

Carroll: Some come to my office to learn by watching me, or I will go to some offices to provide personalized tutoring. Others learn more about RPE from continuing education courses I present. In the future I am planning to have an accredited hands-on and didactic program at my new office. I’m also excited to be a speaker at the 2008 Townie Meeting in Las Vegas. This will be a great opportunity for Hygienetown Townies to learn about RPE.

Dr. John Kwan in Oakland, CA has taken over the Perioscopy company and plans to provide support and repairs for those who own Perioscopes and also plans to provide educational courses. Will you be involved with that?

Carroll: As a strong supporter of Perioscopy, I will definitely be involved as courses are presented to clinicians. Hygienists can learn so much from actually seeing inside a pocket; the infected tissue, the calculus deposits, the bacterial biofilm, the undetected decay, and the effects of various instruments on the root surfaces and the calculus. It’s a great learning experience that all clinicians should have.

For more information on Perio Peak visit: www.periopeak.com.

PerioLase, Nd:YAG

PerioLase is a six-watt, free-running, Nd:YAG (Neodymium: Yttrium Aluminum Garnet) laser designed to perform soft tissue curettage procedures associated with periodontal therapy (Figure 9). It uses digital technology for enhanced performance and reliability. Drs. Robert Gregg and Delwin McCarthy designed the PerioLase laser and the “laser periodontal therapy” that was granted a patent. Drs. Gregg and McCarthy are both dentists from Southern California, former faculty members at UCLA, and clinicians. Dr. Gregg graduated from Georgetown University School of Dentistry and Dr. McCarthy graduated from UCSF School of Dentistry.

How did the PerioLase and the patented periodontal procedure evolve?

Gregg and McCarthy: We began developing and researching lasers for periodontal therapy in 1989 and introduced the PerioLase MVP-7 in 2001, five years later. In 1997, Laser Periodontal Therapy became the first patented periodontal treatment. In 2004 LANAP became the FDA-cleared periodontal protocol.



I’ve seen the animated video of the Laser Periodontal Therapy, but can you give our readers a brief description of the process?

Gregg and McCarthy: The procedure is generally provided a half mouth at each visit. Following probing to determine pocket depth, the laser is drawn across the pocket lining to remove the ulcerated tissue. This opens up the pocket, providing access for power scalers and hand instruments to remove deposits from the root surface. The PerioLase is again used after instrumentation against the pocket lining to finish debridement, bacterial decontamination and establish durable, wet hemostasis and establish coagulation. The tissue is then pressed against the tooth to form a stabilized fibrin clot that creates the “closed system” that allows for regeneration (Figures 7 and 8).

Is anesthesia used for this procedure?

Gregg and McCarthy: Yes, profound local anesthesia is required to accomplish the surgical goals of the protocol for the comfort of the patient. However, the procedure is much less invasive than conventional blade surgery and most patients feel comfortable enough after treatment to return to work.

The American Academy of Periodontology included a session on lasers in its 2007 annual meeting in Washington, D.C. This signals a change in attitude toward lasers by the periodontal community, which has been reluctant until now to accept lasers. Has the research changed their minds?

Gregg and McCarthy: The change has come about due in part to the research published that demonstrates periodontal regeneration using the Periolase and LANAP protocol. Many cases have also been presented on Hygienetown and Dentaltown that show how effective Laser Periodontal Therapy is for bone and new cementum-mediated PDL attachment regeneration.

For more information on Millennium visit: www.millenniumdental.com.
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