Periodontal Endoscopy Hands-on Courses and Observation

We have always had an “open door” clinic policy for Perioscopy/RPE℠ observation.  With nearly 14 years of clinical periodontal endoscope experience we can offer the most advanced hands-on courses currently available.  Proven protocols take time to develop through direct observational research. If you are considering incorporating the dental endoscope technology into your dental practice, but are not quite sure about making the investment, we invite you to our clinic for an informative day of clinical perioscopy observation (shadowing).  If you are interested in attending one of our seminars go to Perioscopy Education and training – lecture schedule

We welcome any clinician to come observe an actual perioscopy/RPE℠ case.  You will be forever changed after spending a day shadowing Judy Carroll or one of her trained specialists.

Students learning excellent perioscopy skills in one day.

We teach what we call a “fast track” perioscopy program, designed to have you mastering many clinical skills in minimal time.  The key is teaching with advanced adjunctive technologies and methods.  We utilize piezo ultrasonic technology, combined with host modulated therapy and regenerative proteins (EMD).  We also teach advanced digital photography for excellent case documentation (very important).  No other perioscopy instruction company in the world teaches the methods with the experience offered at PerioPeak Innovations.


We offer one or two day hands-on instruction courses, depending on the needs of the office.  The basic outline or our hands-on program can be viewed below:

Perioscopy/RPE℠ full day hands-on and didactic program

Schedule for full day of training:

8:00-9:30am -    Power point presentation for entire staff.  Perioscopy videos, image interpretation, review of current research (perioscopy, Periostat, and Emdogain), piezo ultrasonic root instrumentation, adjunctive therapy use reviewed, molecular testing, endo/perio defects, case studies, and case types reviewed.  Insurance codes and verbal skills.

9:30-10:30am -   Typodont root instrumentation with piezo tips and endoscope explorers – technique introduced and reviewed.  Basic understanding of  endoscope set up and trouble shooting.

10:30-12:30pm -    Hands-on perioscopy training, LR quadrant class III or IV case with molars involved.  Vertical bony defect(s), either anterior or posterior to demonstrate placement of Emdogain.  Two handed perioscopy will be introduced.  Adjunctive laser use (Er;Yag, Nd:YAG, diode, or CO2) if interested.

12:30-2:30pm -    Lunch and discussion – review instrumentation technique, review of  research and biology of adjunctive therapies (lasers, host modulated therapy, EMD, antibiotics).  Review of perioscopy fees and insurance codes.

2:30-4:30pm -     Hands-on perioscopy training UR quadrant class III or IV case with molars involved – prefer anterior defect(s) to demonstrate Emdogain placement. Two handed perioscopy reviewed and fine tuned for greater efficiency.

4:30-5:00pm –   Clean up and discussion – Review

 

The majority of the hands-on training revolves around proper piezo ultrasonic technique and a good understanding of periodontal pathogenisis. These skills and knowledge are indispensable and are crucial to perioscopy/RPE℠ program success.  You will be given a lot of hand-outs to build the value of your program and to educate you about the current research and biology of perioscopy/RPE℠.

Important Clinical Preparation:

Both patients must start sub-antimicrobial dose doxycycline 20mg (SDD) twice daily at least 2 weeks before perioscopy/RPE℠.  It is important that the patient take this medication on an empty stomach twice daily an hour before meals.  This medication greatly reduces inflammation and bleeding allowing microscopic debridement and image interpretation to be achieved easily and efficiently.  SDD also accelerates post-op healing by reducing collagenase and osteoclast cells, and activating osteoblast cells; overall results are enhanced with this regenerative medication.  The literature is replete with studies demonstrating efficacy. This is not optional.

 

Water flow must meet the standard below for proper water flow and must flow against gravity as seen in the photo. This requires 60psi with a modified water system.  See photo below.  If proper water flow is not achieved, perioscopy cannot be performed and proper training cannot proceed.  This is not optional.

A major flaw in past perioscopy training was the inability for the instructors to identify proper water flow issues.

All participants of this full day of training and education will receive a certification of Advanced Perioscopy Training. Please contact Judy Carroll, Director, to reserve time.  425-765-6322   All offices trained will have the option of becoming PerioPeak providers of RPE℠ – Regenerative Periodontal Endoscopy℠ and the “Healthy Gums for Life” protocol.

A Satelec P5 Newtron piezo ultrasonic with 2 handles is required, 4 is more ideal. You can order these through your supplier.  In addition, 4 new piezo tips are required.  Please order all piezo tips from Satelec: H4R, H4L, H3, H1 diamond, and one flat wrench.   This is not optional.

One mirror, one probe, one explorer, one syringe for local anesthesia only on the tray.  No hand instruments on tray set up. 4% articaine (septocaine) preferred.

Emdogain can be ordered from your Straumann rep.  We recommend ordering a box of three .7ml – you will also need to order a bag of .22 gauge plastic tips for placement.  If you do not want to learn this portion ordering Emdogain and the tips is not necessary.

 

Perioscopy & Advanced Root Planing Coaching

This is what we call our “Peak Clinical Skills” hands-on course. Half day or full day may be reserved.  Maybe you just need a refresher for more difficult cases, or maybe you just want to simply learn to root plane more efficiently and effectively. Considering Reserving time for valuable hands-on coaching.  Learn to perform advanced root planning using an innovative and systematic approach with Piezo ultrasonic root instrumentation. In addition to mastering innovative piezo techniques, you will learn how to achieve excellent clinical results using our advanced protocol for all stages of periodontal disease.

Our hands-on coaching will take you to the highest skill level possible in root planning or perioscopy, and will cut your root planning time in half.

Make an appointment today and take your clinical skills to the pinnacle of excellence! For more information contact Judy Carroll, RDH, at (425) 765-6322.

 


Perioscopy Training and Education – Lectures and seminar information

Perioscopy Training and Education – Lectures and seminar information

If you are interested in actual hands-on courses go to Perioscopy Hands-on courses and observation

Check our upcoming presentation “Emerging Technologies and Methodologies in Comprehensive Periodontal Therapy” scheduled for 9am on November 9th, 2012 at the Northwest Maritime Center in Port Townsend, WA.( http://www.nwmaritime.org/) in association with the Olympic Peninsula Study Club – check out and like our FB page for this lecture.

This 90 minute  lecture will be provided again in January 2013 with the Mt. Rainier Washington State Dental Hygiene Association, stay tuned for exact date and time.

“Emerging Technologies and Methodologies in Comprehensive Periodontal Therapy”

Presented by

Judy Carroll, RDH, Director and Founder

PerioPeak Innovations

www.periopeak.com

The future is now for revolutionary non-surgical periodontal therapy techniques. Several advanced technologies and methodologies will be discussed in this presentation, including periodontal endoscopy, micro-piezo ultrasonic root instrumentation, host modulated therapy, regenerative proteins, salivary diagnostics, and integrated care. Take a peek into the future of non-invasive comprehensive periodontal therapy with a demonstration of many advanced case studies utilizing synergistic methods. These evidence based techniques, protocols, and technologies will get you excited about the essential paradigm shift already underway in the dental profession.


Presentation outline:

1)      Literature and rationale demonstrating the limitations of current non-surgical periodontal therapy techniques and protocols in clinical dental hygiene.

2)      Periodontal endoscope technology – past, present, and future.  A definition of the parameters and benefits for clinical use in any practice.  Literature review and case studies.

3)      Diagnostic periodontal endoscopy – live endoscopic video images of root decay, crown margin decay, recurrent decay, and root fractures.

4)      Sub-antimicrobial dose doxycycline – SDD:  A review of current literature and the innovative clinical use of SDD for enhanced clinical outcomes in periodontal therapy.

5)      Satelec Piezo root instrumentation -  a review of edged and diamond ultrasonic piezo tips for more thorough root debridement, leading to less hand fatigue, less tissue trauma, greater efficiency, and improved clinical outcomes.

6)      Regenerative proteins – Emdogain – parameters for the non-surgical therapeutic use of regenerative proteins to promote bone fill and restore deep periodontal defects.

7)      Regenerative Periodontal Endoscopy℠ (RPE℠) – a synergistic periodontal therapy approach – pulling it all together.   A demonstration of aesthetic zone and full mouth comprehensive case studies.

8)      Salivary Diagnostics to definitively identify  periodontal pathogens and genetic susceptibility – individualized patient care for more targeted periodontal therapy leading to improved clinical outcomes long term.

9)      Oral-systemic diagnosis and therapy – integrated care through multidisciplinary approach – case studies.

If your association or study club is interested in scheduling this lecture please contact Judy Carroll directly 425-765-6322


Healthy Gums for Life – beyond Perioscopy and “just clean teeth”

What is the “Healthy Gums for Life” protocol and what makes this methodology different?  It’s definitive and comprehensive. While we continue to provide the most minimally invasive and definitive way to treat all stages of periodontal disease through Regenerative Periodontal Endoscopy℠ (RPE℠), we also strive to uncover the truth about “cause and effect” for our clients and to offer integrative solutions for long term results.


PerioPeak Innovations’ Comprehensive Philosophy


 

PerioPeak Innovations is not merely focused on the complete removal of calculus using a dental endoscope and teaching optimal home care (“just clean teeth”), we are also focused on the actual cause of chronic, inappropriate inflammation – which goes well beyond tartar and plaque in most individuals who have periodontal disease.  We also focus on what effect periodontal disease is having on overall health.  We have found that the questions and answers for what is driving the chronic inflammatory response beyond plaque (biofilm) and calculus is rarely explored or addressed with most traditional periodontal protocols.  If the cause is not addressed, which is typically a host response issue, the disease will return within a very short period of time.  Studies have demonstrated well that surgical and non surgical periodontal procedures, followed by close periodontal maintenance every 3 months, does not generally produce long term healthy results.  We believe this is simply due to a lack of education regarding underlying cause, and instead, an unbalanced focus on “just cleaning the teeth”.   Read our publication “Wave Farewell to the Cleaning Lady” for further understanding of our overall philosophy.

Our protocol for comprehensive periodontal care – “Healthy Gums for Life”

Comprehensive Medical Labs - we have researched the most important medical labs to have completed prior to periodontal treatment to help determine underlying issues contributing t0 chronic inflammation in the gums and bone loss around the teeth. The labs we recommend also help us determine what effect, if any, the chronic periodontal infection is having on systemic health. All of our clients are given the opportunity to uncover the truth about a) what systemic issues could be “driving their inappropriate inflammatory response”, and thus the ensuing destruction occurring to their gums and supporting bone, and b) what might be contributing to their systemic health problems and disease processes already well underway.  By identifying underlying issues prior to periodontal treatment the overall clinical outcomes are enhanced.  This is not a one size fits all program, and men and women can have different issues in many cases.  When we provide a complementary consultation for our clients an extensive health history review is performed – medical labs are then recommended.  We provide a comprehensive list of medical labs, which the client then shares with their doctor.  We strongly encourage integrated care with a medical doctor or naturopathic physician of the patients choosing.   Read more about inflammatory biomarkers, vitamin D deficiency, and diabetes and metabolic syndrome.

Other labs we strongly recommend will include HbA1c, thyroid (TSH), vitamin B12, CBC, iron, urinalysis, cholesterol, and triglycerides.  Blood pressure and BMI should also be checked.   Men should consider having their testosterone checked and women are urged to have estrogen, progesterone, and testosterone checked if hormone levels are suspected to be a contributing factor in host response issues and/or bone loss.  Cortisol may also be checked if high stress levels are expected.

Sleep Apnea is an important medical condition which can often go undiagnosed and untreated for many years.  Sleep apnea, especially moderate to severe sleep apnea, will cause hypoxia, a lowered level of oxygen in the blood and thus all the  tissues.  This can be a major contributing factor for all chronic inflammatory diseases.  We suggest an evaluation with a qualified sleep medicine doctor to evaluate this serious condition.

Accumulating evidence provides support to our model of the bi-directional, feed forward, pernicious association between sleep apnea, sleepiness, inflammation, and insulin resistance, all promoting atherosclerosis and cardiovascular disease.  More information here http://www.sleepapnea.org/ or http://sleepapnea.com/

A review of medications - many of our clients are unaware that the medications they are taking may actually be contributing to their bone loss and chronic inflammation.  Certain medications can actually be contributing to periodontal disease, either by creating dry mouth (xerostomea), or directly contributing to inflammation and bone loss (contraceptives and calcium channel blockers for example).  Once a patient is educated they can then discuss options with their physician to either change medications, or try to wean them off them entirely (life style changes may occur if a patient is aware of the periodontal side effects from certain medications).  It all has to do with awareness.

Salivary Pathogen Molecular Testing – we strongly encourage all or our clients to have a simple saliva molecular test (provided at our clinic) to determine definitively and quantitatively which periodontal pathogens are present in their infection.  Every case is different. This highly definitive test directs treatment therapy moving forward and provides valuable information about the decision to use adjunctive systemic antibiotics. This is considered “individualized patient care” since we are not guessing about virulent pathogen involvement, thus we can pinpoint the appropriate short term antibiotic for the infection.  There are currently 11 known periodontal pathogens which are pathogenic (disease causing).   Health history factors and medical lab test results are take into account before any definitive decisions are made for appropriate therapy moving forward.  We often involve the medical doctor (or specialist, such as a cardiologist) in the decision making process based on systemic health issues already present. For example, if a patient has a history of heart disease, atherosclerosis, or stroke, and the molecular pathogen test returns with high levels of certain pathogens known to contribute to vascular inflammation, we are going to be much more proactive in our multidisciplinary treatment approach.  This would mean more frequent molecular testing and possibly a much more frequent supportive periodontal maintenance program. This also empowers the patient through education, if the patient is educated to understand the mouth-body connection, and how it can relate to serious systemic diseases, they can become more involved in their own co-therapy.

click on image to read :  a sample of the salivary DNA pathogen test result, this patient had very high levels of multiple high risk pathogens as shown -  he also had a positive family history of heart disease and an elevated C-reactive protein test score (above 2 – this would indicate that he indeed had systemic inflammation/infection occurring).  Systemic antibiotics were recommended in this case since many of these pathogens enter the vascular system and can create inflammation in many areas throughout the body, contributing to cardiovascular diseases.  (As an additional note, pancreatic cancer victims have been shown to have high levels of antibodies to the pathogen called P. Gingivalis, which is high on this patients’ molecular pathogen test.)

Another example of how molecular testing can help therapy moving forward – if a patient presents with rheumatoid arthritis or multiple sclerosis, or any other type of chronic auto-immune inflammatory disease (recent studies show a connection between oral pathogens and these auto-immune diseases), they have the opportunity through molecular pathogen testing to uncover definitively the presence of oral pathogen species, which may actually be contributing to the inflammatory burden of both their periodontal disease and their systemic disease. This valuable information directs the actual therapy moving forward by pinpointing which systemic antibiotic to use in each case.  Individuals with chronic inflammatory auto-immune diseases such as MS or RA often have periodontal disease characterized by high levels of certain pathogens.

How about hypertension, stroke, or atherosclerosis and the association with oral pathogens? There is a strong association between high levels of two virulent periodontal pathogens and hypertension.  It is crucial that a patient with any type of cardiovascular disease be tested for virulent oral pathogens.  This simple and inexpensive saliva test is at least as important as testing cholesterol for these individuals, if not more important due to the overall added inflammatory burden oral pathogens create.  This has been well published in the literature and is considered to have A level evidence. While no interventional studies have been performed, it does not take much of a leap to connect the dots with regard to overall inflammatory burden and heart attack, stroke, and atherosclerosis.

Salivary DNA testing for IL 1a and IL 1b genetic polymorphism (hyper-inflammatory, or exaggerated immune response) - this is a very important risk factor to determine for a person with periodontal disease and heart disease, and/or family history of heart disease. Knowing this information provides valuable understanding about host response.  Once this information is known, it empowers both the professional and the patient to create optimal strategies moving forward to control hyper-chronic inflammation.  There are many ways to suppress or control this part of “cause”, thus offsetting the inevitable outcome for many, loss of teeth.   Learn more at “genetics”

click on image to enlarge and read: sample PST genetic periodontal disease report – this patient is positive, which means he has a hyper-inflammatory immune response.  Detailed information can be learned on the report provided by Oral DNA Labs. We have found that individuals with auto-immune type diseases such as Lupus and MS tend to score positive for genetic polymorphisms of the inflammatory genes.  The results of this test, combined with the results of the pathogen test and any systemic tests we have had our client complete,  help the decision making process moving forward (integrated care with the physician or other medical professional).  Again, this is individualized patient care, not a one size fits all method. For example, while this polymorphism for hyper-inflammatory response puts this patient at higher risk for periodontal disease, it also demonstrates that this patient is at higher risk for coronary artery disease.  Armed with this information, and the information provided in the pathogen test, we can come together with the cardiologist to form a long term therapy strategy.

Host modulated therapy – very important. A very effective medication for chronic inflammatory periodontal disease has been available for the past 15 years – Periostat (non-antibiotic dose doxycycline – 20mg).   Periostat works as an anti-inflammatory, not an antibiotic.  It effectively reduces bone destroying cells and harmful collagen destroying enzymes. It “resets” the inflammatory response, which in many individuals with chronic periodontitis is “up-regulated and inappropriate”.  In addition, Periostat changes the oral environment to be less conducive to pathogen survival by creating a more oxygenated environment.  In addition to slowing or stopping the progression of periodontal disease, when used adjunctively with active periodontal therapy, Periostat will actually activate bone building cells (osteoblasts). This medication has been published extensively in the periodontal and medical literature over the past 20+ years demonstrating efficacy and statistical significance (no other adjunctive therapy in dentistry has been published as extensively).  However, the ignorance among professionals on this topic remains wide spread, unfortunately.  We strive to educate all patients and professionals about the positive systemic and clinical benefits of using Periostat, either short or long term, depending on host factors.  Read more about host modulated therapy

The generic form of Periostat is 20mg Doxycycline – the Rx is written doxycycline 20mg, dispense 180 tabs, take one tab twice daily on an empty stomach.


The positive effect of Periostat on smokers, diabetics/pre-diabetics, CVD, rheumatoid arthritis, rosacea and osteoporosis

The research with smokers is especially impressive using Periostat since smokers produce very high levels of collagenase.  This medication will also lower blood glucose levels, making it an important adjunctive therapy for people with pre-diabetes and diabetes.  Periostat lowers C-reactive protein, an important inflammatory CVD risk biomarker – demonstrating that is has a very positive overall systemic effect.  This medication is used in medicine under the name Oracea for the treatment of Rosacea, it also has positive clinical benefit for individuals suffering from Rheumatoid Arthritis (RA). Non antibiotic doxycycline is currently being patented for therapeutic use in osteoporosis, demonstrating its positive effect on overall bone health, including the bone around the teeth.


Endodontic diagnosis and treatment – a tooth nerve and blood supply (pulp) can be damaged by chronic periodontal disease (pathogen infection can cause the nerve of the tooth to die) or trauma  A tooth infected/injured internally will require a root canal treatment as well as RPE℠ to achieve long term results and bone fill.  We call this type of defect a combined endo/perio lesion.   See example below:

tooth #18 had 12-15mm pockets and was determined to be “non vital”, meaning the infection was now inside the tooth.  A simple root canal was performed on the same day that RPE℠ was completed on this tooth.

10 weeks after endodontic treatment (root canal) and RPE℠ combined treatment for endo/perio lesion – nice bone fill and nice tight tissue. We give our patients the option for combined treatment like this over extraction and implant.  Recent long term studies are very positive  for “hopeless” endo/perio cases when using regenerative periodontal methods in addition to root canal therapy.

Nutrition and antioxidant levels -

We discuss nutrition and supplementation as a main strategy  for addressing chronic inflammation.  We know that a pro-inflammatory diet (refined carbohydrates), combined with a low intake of antioxidants (fresh fruits and vegetables), can lead to severe inflammation in the gums and certainly throughout the body (oxidative stress). In addition, a person with a higher BMI (a basal metabolic index over 24 – overweight) due to a high pro-inflammatory and high fat diet is at even higher risk for chronic inflammation due to elevated cytokine levels from the adipose cells – fat cells.  Adipose cells will actually trap important protective antioxidants – fat cells also trap an important anti-inflammatory hormone, vitamin D.  The body cannot use what is trapped in adipose cells.  In addition, low or deficient vitamin D levels will actually lower the very important master antioxidant in the body called glutathione.  The combined effect of low antioxidant levels (oxidative stress), high carbohydrate diet (pro-inflammatory diet), higher than normal fat cells (high BMI) and vitamin D deficiency, leads to the “perfect storm” for chronic inflammatory periodontal disease and advanced bone loss.  In addition, many serious systemic diseases may simultaneously become an issue (osteoporosis, diabetes, cardiovascular diseases, autoimmune diseases, cancer, RA, and MS).

We provide a non-invasive antioxidant scan in our clinic to help our clients understand what is going on at a cellular level in their own body. We find the visual imagery of the computer generated chart to be beneficial when discussing oxidative stress (low antioxidant levels) and its important role in chronic inflammation and disease. While the biophotonic scanner is only measuring 14 of the known 1400 antioxidants, research shows this to be at the very least a baseline indicator for overall antioxidant levels.  Read the research about periodontal disease and low antioxidant levels.


The patient above is having her cellular carotenoid antioxidant levels checked with a simple scanning device called a biophotonic scanner. This technology was featured on the Dr. Oz show where he demonstrated that his audience participant scores were very low due to SAD, or “the Standard American Diet”, which is very low in foods containing antioxidants and high in refined carbohydrates.  Other countries around the globe tend to score much higher on average.  Suggestions and solutions were given to the patient above based on her low score and her overall dietary habits.  go to www.pharmanexmd.com for all the research on the biophotonic scan and oxidative stress.  Another good web site to read is www.dentalantioxdants.com

Mouth breathing, tongue thrust, or clenching/bruxing parafunctions -  many of the clients we help have one or all three of these “parafunctions”.  These are habits that are very destructive to the teeth and gums over time.  We evaluate these issues closely and recommend the appropriate therapy moving forward.  We have found that many of our clients have never been advised of these rather serious periodontal issues.  To learn more about the therapy we highly recommend for these parafunctions and to find a local provider go to www.iaom.com (The International Association for Orofacial Myology).

The patient above is a good example of the damage from a  long term tongue thrust parafunction. Note the “open bite” and ensuing “traumatic occlusion” (heavy bite on back teeth) as a result.  this creates exacerbated bone loss problems on the posterior teeth, and sometimes even fractures of the back teeth.

Mouth breathing can be very destructive to the periodontal tissues due to dryness (xerostomia).  The natural enzymes in saliva help protect the gums from inflammation and disease.

The above patient is a good example of a mouth breather with a tongue thrust parafunction as well. Note the severe  inflammation and the advanced bone loss in the front teeth.  Chronic inflammation due to mouth breathing combined with tongue thrust is a very destructive combination for bone loss and loosening of the teeth.  This is all very treatable with an integrated approach using Orofacial Myology, definitive periodontal therapy (RPE℠), proper home care habits, and supportive periodontal therapy maintenance every 3 months.

Pulling it all together - Exercise, stress management, diet, and smoking cessation - PerioPeak Innovations has partnered with the world renown Cleveland Clinic in association with The American Academy for Oral Systemic Health (AAOSH) to provide optimal solutions for these four important areas relating to “cause” in chronic disease progression.  We are able to extend discounts to our clients for any of the Wellness Institute Programs at the Cleveland Clinic. Having attended lectures at this amazing hospital in 2012 we came away very impressed with the comprehensive, evidence based programs they offer.  If a patient is struggling in any of these areas we highly recommend they consider contacting the Cleveland Clinic Wellness Center for optimal integrated care approach -  http://my.clevelandclinic.org/wellness/cleveland-clinic-wellness.aspx and http://www.time.com/time/magazine/article/0,9171,1904143,00.html

Home Care –

We suggest current home care regimens based in science, our own observations, as well as common sense. While some dentists and periodontists tend to dislike the use of a water pik device, we strongly encourage our clients to use this valuable tool daily.  We also highly recommend a sonic toothbrush, such as Sonicare or Oral B Triumph.   We suggest “dry brushing” the lower front teeth prior to using toothpaste, this has significant impact on lowering tartar build up on the lower front teeth.  In addition to good mechanical removal of plaque biofilm, we suggest the latest in innovative home care products below:

1.  Spry xylitol products used five times per day (Strive for Five – chewing gum, mints, candies, gels, etc) http://www.xlear.com/spry.aspx When using xylitol products look for a label indicating that it has 100% xylitol.

2.  Closys toothpaste and mouthrinse (Rowpar chlorine dioxide products available at Walgreens) ( http://www.closys.com/pros/research.html)

3.  Daily oral probiotic – Evora Plus from Oragenics (http://forevoraplus.com/)

4.  Daily use of Periogen to keep tartar build up to a minimum between periodontal maintenance cleanings.  (www.periogen.com)

Biomarkers for Cardiovascular and Periodontal Diseases

 

What is a biomarker? How does this relate to cardiovascular or periodontal diseases?

A biomarker is anything that can be used as an indicator of a particular disease state, but it is typically a protein which can be measured in the blood and may reflect the severity of a disease.  The two biomarkers connected to both cardiovascular diseases and periodontal disease, are C-reactive protein (CRP) and PLAC2.

C-reactive protein was discovered almost a century ago, it is a biomarker for a protein produced by the liver in response to inflammation and infection.  Recent research suggests that patients with elevated basal levels of CRP are at increased risk of hypertension, diabetes, and cardiovascular disease.  Coronary artery disease can result from white blood cells responding to chronic inflammation in the heart arteries.  A level above 2.4 has been associated with double the risk of coronary event compared to levels below 1.   Periodontal disease was found to be a cause for elevated CRP levels some years ago.   Periodontal infection involves a chronic bacterial infection possibly leading to bacterial bi-products entering the blood stream and triggering CRP to elevate.  ”Periodontal disease needs to be considered as a major contributor to increased levels of CRP by the medical community,” said Dr. Steven Offenbacher, member of the American Academy of Periodontology.  

Read more here  http://www.perio.org/consumer/happy-heart.htm

However, CRP levels in this instance should be used only as one indicator for further exploration.  If this test is normal, it can actually be a false positive for chonic periodontal infection and inflammation.  Often, we have actually tested and treated patients with advanced periodontal disease who have no elevation of CRP whatsoever.  CRP alone is not an accurate assessment for a physician or cardiologist to use for thorough diagnosis of a chronic inflammatory state.  On the other hand, we have also treated patients with elevated CRP (high risk catagory over 2.4) who experience a reduction of CRP levels to normal after our treatment.  Studies show that the adjunctive use of a medication called Periostat will actually reduce CRP levels with traditional periodontal therapy.  CRP, or hs-CRP (high sensitivity CRP), can be requested during a routine blood draw with any physician or lab.  A patients overall health and more comprehensive labs should also be taken into consideration. While CRP is a “marker”, it is not a “player”, as we will see with the biomarker PLAC2 below.

PLAC2 is also a measure of a protein level in the blood.  This test was approved by the FDA in 2003.  PLAC2 is an enzyme which co-traffics with LDL (low density lipoproteins – bad cholesterol), then oxidizes in the arteries, leading to white blood cells coming to the area – foam cells are then formed, which leads to increased cytokines (inflammatory signaling enzymes) and the release of MMP 9  (tissue destroying enzymes)…this leads to a weakened fibrous cap (which covers the plaque build up in the arteries)…if this fibrous cap ruptures, as PLAC2 seems to promote, the person ends up with a thrombus (blood clot) – leading to heart attack or stroke. 

The only known cause of elevated PLAC2 at this time is periodontal disease.  Oral pathogens can travel into arteries from the mouth. PLAC2 is a major “player” in deadly coronary heart disease.   Anyone, especially anyone with hyperlipidemia (high cholesterol) and periodontal disease, should seriously consider having this biomarker checked.  If traditional approach periodontal treatment is not reducing this biomarker we highly recommend more definitive periodontal treatment to eliminate periodontal pathogens, chronic infection, and the chronic inflammation associated with it.  

To learn more about the PLAC2 test click here http://www.ocaheart.com/patient_services/patient_education/testsandprocedures/PLAC.asp

Vitamin D deficiency – Its impact on oral and systemic health

Vitamin D deficiency – could this be contributing to your periodontal disease problem?

Vitamin D deficiency is a common problem world wide and is gaining much attention with researchers.  Vitamin D deficiency may be a major risk factor for many chronic diseases, such as:  periodontal disease, bone loss in the jaw and tooth loss, many types of cancer, numerous cardiovascular diseases, several auto-immune conditions, metabolic syndrome (weight gain and high BMI, prediabetes and type II diabetes, hypertension, low HDL cholesterol and high LDL cholesterol levels, high triglycerides), low mineral bone density (osteopenia), and osteoporosis.

What is significant about this is that periodontal disease in and of itself has been associated with many of the chronic diseases mentioned above.    We encourage anyone with any degree of periodontal disease to have the necessary blood tests performed to determine vitamin D levels.

Published papers and more information about vitamin D deficiency:

J Tenn Dent Assoc. 2011 Spring;91(2):30-3; quiz 34-5.
Vitamin D and its impact on oral health–an update.

Stein SH, Tipton DA.

Source

Department of Periodontology, College of Dentistry, University of Tennessee Health Science Center, Memphis, Tennessee, USA.

Abstract

Vitamin D has been shown to regulate musculoskeletal health by mediating calcium absorption and mineral homeostasis. Evidence has demonstrated that vitamin D deficiency may place subjects at risk for not only low mineral bone density/osteoporosis and osteopenia but also infectious and chronic inflammatory diseases. Studies have shown an association between alveolar bone density, osteoporosis and tooth loss and suggest that low bone mass may be a risk factor for periodontal disease. Several recent reports demonstrate a significant association between periodontal health and the intake of vitamin D. An emerging hypothesis is that vitamin D may be beneficial for oral health, not only for its direct effect on bone metabolism but also due to its ability to function as an anti-inflammatory agent and stimulate the production of anti-microbial peptides.

Eur J Intern Med. 2011 Aug;22(4):355-62. Epub 2011 May 31.

Novel roles of vitamin D in disease: What is new in 2011?

Makariou S, Liberopoulos EN, Elisaf M, Challa A.

Source

Department of Internal Medicine, Medical School, University of Ioannina, Ioannina, Greece; Department of Child Health, Medical School, University of Ioannina, Ioannina, Greece.

Abstract

Vitamin D is a steroid molecule, mainly produced in the skin that regulates the expression of a large number of genes. Until recently its main known role was to control bone metabolism and calcium and phosphorus homeostasis. During the last 2 decades it has been realized that vitamin D deficiency, which is really common worldwide, could be a new risk factor for many chronic diseases, such as the metabolic syndrome and its components, the whole spectrum of cardiovascular diseases, several auto-immune conditions, and many types of cancer as well as all-cause mortality. Except for the great number of epidemiological studies that support the above presumptions, vitamin D receptors (VDRs) have been identified in many tissues and cells. The effect of vitamin D supplementation remains controversial and the need for more persuasive study outcomes is intense.

Copyright © 2011 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.

Mol Nutr Food Res. 2011 Jan;55(1):96-108. doi: 10.1002/mnfr.201000174. Epub 2010 Sep 7.

A review of the critical role of vitamin D in the functioning of the immune system and the clinical implications of vitamin D deficiency.

Schwalfenberg GK.

Source

University of Alberta, Edmonton, Alberta, Canada. schwalfe@ualberta.ca

Abstract

This review looks at the critical role of vitamin D in improving barrier function, production of antimicrobial peptides including cathelicidin and some defensins, and immune modulation. The function of vitamin D in the innate immune system and in the epithelial cells of the oral cavity, lung, gastrointestinal system, genito-urinary system, skin and surface of the eye is discussed. Clinical conditions are reviewed where vitamin D may play a role in the prevention of infections or where it may be used as primary or adjuvant treatment for viral, bacterial and fungal infections. Several conditions such as tuberculosis, psoriasis, eczema, Crohn’s disease, chest infections, wound infections, influenza, urinary tract infections, eye infections and wound healing may benefit from adequate circulating 25(OH)D as substrate. Clinical diseases are presented in which optimization of 25(OH)D levels may benefit or cause harm according to present day knowledge. The safety of using larger doses of vitamin D in various clinical settings is discussed.

Copyright © 2011 WILEY-VCH Verlag GmbH & Co. KGaA, Weinheim.

J Environ Pathol Toxicol Oncol. 2009;28(1):1-4.

Modern concepts in the diagnosis and treatment of vitamin D deficiency and its clinical consequences.

Edlich R, Fisher AL, Chase ME, Brock CM, Gubler K, Long WB 3rd.

Source

University of Virginia Health System, Charlottesvill, VA, USA. richardedlich@gmail.com

Abstract

It is the purpose of this comprehensive report to outline a revolutionary strategy to prevent vitamin D deficiency in our nation. Vitamin D is a unique vitamin. Its metabolic product, calcitriol, is a profound secosteroid hormone that has impact on over 1000 genes in the human body. Recent clinical research has implicated vitamin D deficiency as a major factor in the etiology of rickets, a wide variety of cancers, as well as hypertension, stroke, heart attack, diabetes, bone fractures, periodontal disease, and even multiple sclerosis. There are two forms of vitamin D utilized in the human body: D2 and D3. Measurement of 25(OH)D is the most reliable method of detecting vitamin D deficiency. Several methods, including high-performance liquid chromatography (HPLC), chemoluminescence, and radioimmunoassay (RIA), have been developed for the measurement of total 25(OH)D levels. Prevention and treatment of vitamin D deficiency is accomplished by regulated sun exposure as well as vitamin D, supplementation. This information describing our plan to prevent vitamin D deficiency in the patients and employees of Legacy Health System is a landmark accomplishment that should be replicated in every healthcare setting in our country to prevent vitamin D deficiency.

Important re vitamin D. When vitamin D is converted to its active form, vitamin K and small amount of vitamin A are needed (found in orange veggies or supplements). Vitamin K can be supplemented or found in the following foods: parsley, kale, spinach, Brussels sprouts, Swiss chard, green beans, asparagus, broccoli, kale, mustard greens, turnip greens, collard greens, thyme, romaine lettuce, sage, oregano, cabbage, celery, sea vegetables, cucumber, leeks, cauliflower, tomatoes, and blueberries.

The ideal vitamin D level is 50-80, some physicians do check vitamin K when they discover this deficiency. The Cleveland Clinic recommends a multivitamin at least daily for all. We like to see our patients take nano-vitamins (LifePak Nano) by Pharmanex, or other comparable high quality supplement for greater absorption. We are also giving our patients a list of foods to add to their diet. Most people have never been taught what or how to eat to be healthy.

In our experience most adults need a minimum of 2000IU vitamin D supplementation, even more in the winter months. If someone is severely deficient they will be put on high doses (Rx by their physician – 50K IU per week), then retested in 8-12 weeks. The patient is then put on a maintenance dose daily and monitored. Vitamin D is found in fish and fortified foods but one would have to eat a lot of fish and get sun daily with no sun screen to keep normal levels typically (most do not have this lifestyle). Many find it hard to believe that all that milk drinking and taking a multivitamin is not enough. If you are not supplementing you can assume you are deficient, its a given usually. Get tested.

Before and after pictures of a non invasive periodontal disease treatment, RPE℠ – Regenerative Periodontal Endoscopy℠

Before and after pictures of a patient treated at PerioPeak Innovations with a non-invasive treatment approach called Regenerative Periodontal Endoscopy℠, or RPE℠.

 The young female patient below came to PerioPeak with advanced stage periodontal disease, with generalized 5-13mm pockets.  This patient was very interested in a non invasive approach over traditional surgery to treat her periodontal disease.  She had undergone traditional root planing (deep cleanings) with marginal results, she continued to have deep periodontal pockets with chronic infection, bleeding, and inflammation.

This patient opted for Regenerative Periodontal Endoscopy℠, RPE℠ over periodontal surgery and extractions of her teeth.

See her before and after photos

  

             Before RPE℠ – 10mm pocket                                            10 months after RPE℠ – 2mm

 

 

                Before RPE℠ – 11mm pocket                                 10 months after RPE℠ – 1mm

 

            Before RPE℠ - 13mm pocket                                           10 months after RPE℠ – 2mm

   

Before RPE℠ 7-8mm  with bleeding                                      After RPE℠ 2mm – health restored

   

    Before RPE℠  – 8mm pocket                                             After RPE℠ 3mm – health restored

   

    Before RPE℠ – 8mm pocket                                 10 months after RPE℠ – 3mm health restored

    

Before RPE℠   9-10mm pockets                                      After RPE℠ – 2mm tight healthy gums

 

Before RPE℠ 8-9mm pockets                                                     After RPE℠ 2-3mm

 

Before RPE℠ – 7mm furcation                                      After RPE℠ – 2mm – health restored

 

Before 7mm                                                               After – 3mm

View the before and after x-rays and more information about this case here.

View more cases here - Real people, real results.

Watch an actual RPE℠ procedure on our You Tube Video

Periodontal Surgery Efficacy – What does the literature say?

The Literature Does Not Support Traditional Periodontal Surgery vs Non Surgical Methods – Why is it still “standard of care”?

While traditional periodontal surgery (osseous or flap gum surgery) is still “standard of care” for the treatment of deep gum pockets, the literature simply does not support it.  Why is it still standard of care?  Great question.  These methods have been ”steeped in tradition, unhampered by progress” - for many decades. We encourage all periodontal sufferers to carefully review the research before undergoing any type of periodontal surgery. What will the results consistently demonstrate?  How will the gums and the teeth look after surgery?  Will there be long term sensitivity?  Will the results be long term?  It is our suggestion that ”informed consent” about the results of traditional periodontal surgery be brought to the forefront of public understanding.  

We strongly encourage anyone facing periodontal surgery to review pictures of surgical case results, obtain direct patient testimonials, as well as review the published research carefully.  Knowledge is empowering. 

 

 Clin Periodontol. 1987 Sep ;14 (8):445-52 3308969

4 Modalities Of Periodontal Treatment Compared Over 5 Years.
S P Ramfjord , R G Caffesse , E C Morrison , R W Hill , G J Kerry , E A Appleberry , R R Nissle , D L Stults
The purpose of the present study was to assess in a clinical trial over 5 years the results following 4 different modalities of periodontal therapy (pocket elimination or reduction surgery, modified Widman flap surgery, subgingival curettage, and scaling and root planing). 90 patients were treated. The treatment methods were applied on a random basis to each of the 4 quadrants of the dentition. The patients were given professional tooth cleaning and oral hygiene instructions every 3 months. Pocket depth and attachment levels were scored once a year. 72 patients completed the 5 years of observation. Both patient means for pocket depth and attachment level as well as % distribution of sites with loss of attachment greater than or equal to 2 mm and greater than or equal to 3 mm were compared. For 1-3 mm probing depth, scaling and root planing, as well as subgingival curettage led to significantly less attachment loss than pocket elimination and modified Widman flap surgery.

 For 4-6 mm pockets, scaling and root planing and curettage had better attachment results than pocket elimination surgery. For the 7-12 mm pockets, there was no statistically significant difference among the results following the various procedures. 

Dr. Caffesse emphasized, and was quite surprised, that his group had shown that there is no benefit to resective pocket reduction whatsoever.

Actual AFTER photo of osseous periodontal surgery

 

The study below actually demonstrates that patients are far worse off  AFTER periodontal surgery:

 

J. Clin. Perio. Volume 4 Issue 4 Page 240-249, December 1977

Periodontal Surgery In Plaque-Infected Dentitions
A clinical trial was performed to study the result of periodontal treatment following different modes of periodontal surgery in patients not recalled for maintenance care. The material consisted of 25 patients distributed into 5 groups. Following an initial examination, all patients underwent presurgical treatment including case presentation and instruction in oral hygiene measures. This instruction was given once. The various patient groups were then subjected to one of the following surgical procedures: 1) the apically repositioned flap operation including elimination of bony defects 2) the apically repositioned flap operation including curettage of bony defects but without removal of bone 3) the “Widman flap” technique including elimination of bony defects 4) the “Widman flap” technique including curettage of bony defects but without removal of bone 5) gingivectomy including curettage of bony defects but without removal of bone. Six, 12 and 24 months after completion of the treatment, the patients were recalled for assessment of their oral hygiene standard and periodontal conditions.

The results showed that case presentation and oral hygiene instruction given once, only temporarily improved the patient’s oral hygiene habits. Renewed accumulation of plaque in the operated areas resulted in recurrence of periodontal disease including a significant further loss of attachment. All five different techniques for surgical pocket elimination were equally ineffective in preventing recurrence of destructive periodontitis.

Summary:

The rate of destruction for “no surgical intervention” vs “perio surgery”: Nyman & Linde & Rosling of Switzerland, in Journal of Clin Perio, 4:240,1977.

The rate of bone destruction was .1-.3 mm/yr. with no periodontal surgery performed vs. 1-2mm/yr. rate of bone destruction after periodontal surgery. 

Informed consent is an important issue when discussing all the options for periodontal treatment.  We encourage all periodontal sufferers to thoroughly educate themselves about expected clinical outcomes of all available periodontal surgery treatment options. 

What about long term outcomes with traditional periodontal therapy and surgical treatment methods?

J Clin Periodontol. 2012 Jan;39(1):73-9. doi: 10.1111/j.1600-051X.2011.01811.x. Epub 2011 Nov 7.

Tooth loss in periodontally treated patients: a long-term study of periodontal disease and root caries.

Source

Division of Cardiovascular Medicine, Department of Medical and Health Sciences, Linköping University, Center for Oral Rehabilitation, County Council of Östergötland, Sweden. nils.ravald @lio.se

Abstract

AIM: To study periodontal conditions, root caries, number of lost teeth and causes for tooth loss during 11-14 years after active periodontal treatment.

MATERIAL AND METHODS:

Sixty-four patients participated in the follow-up study. Reasons for tooth loss were identified through previous case books, radiographs and clinical photos. To identify factors contributing to tooth loss, a logistic multilevel regression analysis was used.

RESULTS:

The number of lost teeth was 211. The main reason was periodontal disease (n = 153). Due to root caries and endodontic complications, 28 and 17 teeth, respectively, were lost. Thirteen teeth were lost for other reasons. The number of teeth (p = 0.05) and prevalence of probing pocket depths, 4-6 mm (p = 0.01) at baseline, smoking (p = 0.01) and the number of visits at dental hygienists (p = 0.03) during maintenance, significantly contributed to explain the variation in tooth loss.

CONCLUSION:

Previously treated patients at a specialist clinic for periodontology continued to lose teeth in spite of maintenance treatments at general practitioners and dental hygienists. The main reason for tooth loss was periodontal disease. Tooth loss was significantly more prevalent among smokers than non-smokers. Tooth-related risk factors were smoking, low numbers of teeth and prevalence of periodontal pockets, 4-6 mm.

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In many cases surgical intervention and extractions of teeth should be a last resort.  It is our assertion that definitive non surgical attempts should be considered as a first phase treatment approach to reduce the need for surgical intervention and tooth extractions.  We also highly recommend that sufferers of chronic periodontal disease look closely in to host factors (deficiencies, blood sugar levels, medications contributing to gum disease, genetic conditions, molecular diagnosis of pathogen levels, etc.) which may be contributing to their periodontal disease and yet go untreated.  Without finding the “cause”, any treatment approach will fail in the long term, as demonstrated in the study above.

 Learn more

Tooth and Gum Abscess Symptoms and Treatment – Pictures and x-rays of abscessed teeth

Tooth and gum abscesses can be treated successfully without requiring extractions and implants.  If you have been diagnosed with a tooth or gum abscess, or feel you may have an abscess, please read and view pictures below for symptoms and appearance of an abscess.  We also demonstrate actual cases treated with an affordable and advanced treatment option called RPE℠ – Regenerative Periodontal Endoscopy℠.   Tooth extractions and expensive implants may not be necessary.

1) Periodontal Abscess picture and x-ray

           

The above picture clearly shows a “pimple” on the gum.  Upon probing (measuring the depth of the infection) we find a 10mm pocket.  The x-ray clearly demonstrates the bone loss associated with a periodontal abscess.  This tooth was very loose upon examination, with severe inflammation and heavy bleeding noted.  Symptoms included tender and painful gums, odor, pus coming out from all areas around the tooth, and shifting or extruding of the tooth

This patient was advised to have this front tooth extracted by her dentist and periodontist, and it was recommended to have an implant placed.  A very expensive treatment option, totaling $6,000. She decided to research less invasive and less expensive alternatives – she found the PerioPeak Innovations clinic, and the RPE℠ – Regenerative Periodontal Endoscopy℠ treatment protocol.  This patient was treated in 2004 and remains stable.  See her results below:

   

 4 weeks  after RPE℠ - no abscess, health restored.        The  x-ray reveals bone fill after 6 months

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Below is a periodontal abscess treated at PerioPeak Inovations – this tooth had been deemed hopeless by the periodontist:

 

advanced bone loss and mobility of 19                13mm pocket with an advanced furcation defect

The above patient presented with several periodontal abscesses treated successfully with RPE℠.  In the above image a periodontal abscess can clearly be seen on the distal root of tooth #19.  The tooth was determined to be vital, so no root canal therapy was indicated. Her dentist and periodontist had recommended extraction of this tooth.  See more pics below demonstrating the severity of this abscess.

 

deep pocket 13mm  before RPE℠                                   Before RPE℠ – 11mm pocket

 

                                        6 months after RPE℠ – health restored – 2mm

 

Note the healthy tissue, from 11-13mm pockets to 2mm and excellent bone fill in only 6 months, no extraction needed.  Periodontal abscesses, even in the advanced stage, can be repaired with non invasive RPE℠.

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Periodontal Abscess:

 

swollen, red, loose tooth – 7mm                             2 weeks after RPE℠ – 1mm health restored

Traditional Treatment for a Periodontal Abscess is often extraction of the tooth, traditional root planing with root canal therapy, or periodontal surgery, depending on the severity of the infection and bone loss.  Sometimes a traditional deep cleaning is combined with antibiotics to try to stop the infection.  This treatment approach is typically non effective since it is not definitive (performed blindly).

We offer an advanced solution for abscessed teeth, which is outlined throughout this web site.  Abscessed teeth are non invasively treated in our clinic with an innovative endoscopic technique called RPE℠ – Regenerative Periodontal Endoscopy℠.  This treatment is unique to PerioPeak Innovations – we utilize regenerative proteins, periodontal endoscopy, and enzyme inhibitors to achieve remarkable results affordably.

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2)  Periodontal/Endodontic Abscess Picture and X-ray

 

Before RPE℠ – loose, abscessed tooth          After RPE℠ – health restored

This Endodontic/periodontal abscesss was considered hopeless with traditional methods, this patient was advised to have this tooth extracted. She was not a candidate for an implant due to her titanium allergy.  She came to PerioPeak for a second opinion. Root canal therapy was completed to eliminate the infection in the nerve, followed by a simple RPE℠ procedure.

     

Before RPE℠ – deep periodontal pockets observed around entire tooth, measuring 10mm -  RPE℠ was completed the same day as root canal procedure, optimizing both therapies and creating a rapid healing response, preventing the need for extraction.

   

RESULTS: 6 months after RPE℠ treatment and root canal therapy- nice bone fill and very tight, healthy gum tissue.  This patient was able to avoid extraction of this tooth.

Home Remedies and associated serious health risks: 

We do not condone the use of home remedies of any kind for any type of periodontal or endodontic abscess.   The virulent, pathogenic bacteria involved in periodontal (gum) abscesses can enter the blood stream and respiratory track, travel to the heart, lungs, brain, arteries, and other organs – promoting infection and inflammation throughout the body (creating an overall inflammatory burden effect), and possibly leading to brain abscesses and other very serious health problems, such as atherosclerosis, stroke, heart attack, diabetes complications, and preterm births.  Recent research also reveals a connection between periodontal disease and alzheimer’s, MS, and rheumatoid arthritis.  The research is replete with studies demonstrating the many negative health consequences associated with the pathogen bacteria involved in gum and tooth abscesses.

Virulent high rish periodontal pathogens associated with tooth and gum abscesses and major health problems:  AA (Aggregatibacter Actinomycetemcomitans), Porphyromonas Gingivalis (Pg), Tannorelia Forsythia (Tf), Treponema Denticola (Td), and Eubacterium Nodatum (En). 

For this reason we recommend that tooth and gum abscesses be treated as a serious medical condition requiring immediate professional attention.   Consider contacting PerioPeak for a free consultation if you have already been diagnosed with a tooth abscess, or feel you may have this condition.

See more pictures of abscessed teeth treated successfully with RPE℠.

Alternative Periodontal Disease Treatment Options for Deep Gum Pockets

Alternative Gum Disease Treatment Options for Deep Gum Pockets

This post will define the available professional “alternative gum disease treatment options” for deep gum pockets.  

When traditional therapies such as root planing (deep cleaning) with antibiotics, or basic laser periodontal therapy are exhausted, the next indicated step for a more definitive treatment to stop infection in unresponsive deep pockets may be traditional periodontal surgery.  However, many individuals decide to seek alternatives to traditional periodontal surgery for the following reasons in our experience:  to avoid pain and long term tooth sensitivity, to prevent large gaps or black triangles between the teeth, to avoid recession of the gums following surgery, to avoid extractions of teeth deemed hopeless,  and to avoid the potentially huge costs associated with periodontal surgery and tooth replacement. 

The following periodontal treatment options are at this time considered to be alternatives to traditional periodontal surgery.

Regenerative Periodontal Endoscopy℠ – Non invasive procedure to promote closure of deep gum pockets and repair bony defects.

This non-invasive procedure employs the use of a periodontal endoscope.  RPE℠ differs from a standard perioscopy procedure in many ways.  The inclusion of enzyme inhibitors and regenerative proteins to promote reattachment of pockets and bone fill.  In addition, RPE℠ is performed with very precise and efficient tools (piezo diamond tips), which allows skilled clinicians to complete the procedure more efficiently while preventing root damage and tissue trauma from occurring.   An occlusal adjustment is often performed to aid in overall healing. Teeth deemed hopeless can be treated with RPE℠ as an alternative to extractions due to the non-invasive nature of the procedure.

before RPE℠ After RPE℠ JPeg

Before RPE℠  - deep gum pockets/bone loss           After RPE℠ – reattachment of gum pockets/bone fill

See case studies (actual patients of PerioPeak Innovations)

Perioscopy – visual removal of tartar in deep pockets only

This non-invasive procedure employs the use of a dental endoscope to “see” microscopically into deep periodontal pockets. This allows the clinician to better remove the tartar and plaque (biofilm) from the roots which have already been root planed blindly without success.   It is simply “visually enhanced root planing” (removing tartar from pockets).  Local anesthetic is used.   The tools used to actually remove the root deposits (tartar) vary widely from clinician to clinician, as well as the actual proficiency and skill.   Results and long term results will vary due to skill level, experience, and technique.  This procedure may include adjunctive therapies such as antibiotics, either placed beneath the gums or given systemically.  While there is some impressive published research to support perioscopy, it has still not been embraced by the main stream dental profession as a viable treatment option for periodontal disease.  In some offices perioscopy is only employed when all other methods have been exhausted rather than utilizing it as a first phase treatment approach. 

Explorer In Hand ScalerTipOnCalculus

Perioscope in hand (miniature fiber optic)   -   48X magnification on a 10,000 pixel color monitor allows for real time pinpoint tartar removal in deep gum pockets.

 

PerioProtect – a non-definitive approach for first phase treatment, but an impressive maintenance program if necessary.

PerioProtect is a relatively new treatment non-definitive option for patients with unresolved periodontal infections and periodontal pockets.  This professional treatment involves having a custom mouth tray fabricated by the dentist  for the patient to use at home.  These trays are then filled with antibiotics, or antimicrobials such as hydrogen peroxide (depending on the need), and are worn several times a day, up to several hours a day.  PerioProtect is  intended to be an adjunctive therapy with traditional root planing and periodontal maintenance cleanings.  No surgery is performed to correct pockets and no dental endoscope is employed to aid in the removal of tartarand biofilm from deep gum pockets, therefore periodontal infections and gum pockets may continue to be a chronic problem. PerioProtect trays are supposed to kill bacteria in deep pockets, but the depth that the medicament will reach remains questionable due to lack of research.  The company has gone to great lengths to market their product but to date have only demonstrated their medicament reaching one pocket of 6mm.  Tartar trapped under the gum in deep pockets is not removed by this product, therefore results may be temporary.

Perioscopy and Alternative Treatment Options to Reduce Deep Gum Pockets

Periodontal Disease Treatment Options for Treating Deep Gum Pockets

It is important to consider all options very carefully and to find what actually works well long term (results as demonstrated by real case studies and published research).  In addition, it is also important to consider how a particular treatment fits into overall goals, expected outcomes, lifestyle, convenience, comfort, and budget.    Knowledge is empowering, we encourage all periodontal sufferers researching periodontal treatment options to consider all this information carefully.

Regenerative Periodontal Endoscopy- RPE℠

This advanced endoscopic procedure eliminates cutting the gums open. Instead, reattachment of the pockets are promoted with microscopic removal of calculus and the addition of regenerative protiens and systemic enzyme inhibitors.  RPE℠ may eliminate the need for aggressive periodontal surgery and/or extractions, but we encourage all patients to consider close monitoring by a periodontist throughout their life if they have a history of chronic periodontal problems.  RPE℠ is completed in one appointment and local anesthetic is used for comfort. 

Gum gaps are minimized, or not created, following RPE℠ as with traditional periodontal surgery. 

Picture1

6 weeks following RPE℠ – a nice esthetic result, health restored.

contact us for more information about RPE℠

Root Planing (deep scaling):

Root planing is still the “standard of care’ for the initial phase in treating all stages of periodontal disease, yet it is a non definitive, blind treatment approach.  The literature does not support this traditional approach in the advanced stages of periodontal disease –  it is usually followed by periodontal surgery due to the visual and clinical limitations. Root planing, or deep cleaning, is generally performed with local anesthetic (Novocaine), and is usually completed by sections, or quadrants.  The clinician performing this treatment employs the use of either standard aggressive scaling tools (curettes), or an ultrasonic scaling device, or both.  The goal of this procedure is to remove as much tartar and plaque from the roots below the gum line as possible by tactile means (blindly).  The deeper the pockets, the more challenging.   Sometimes roots can be damaged by “over-planing”, or over-scaling.   In addition, many studies over decades show that gum pockets with a depth over 4mm may have up to 30-50% of the calculus (tartar) left behind following traditional root planing.  

Picture2 5 Perioscopy after SRP

Before root planing (deep cleaning)             After root planing (up to 50% of tartar left on root)

Below is a list of adjunctive therapy options used with root planing in an attempt to obtain a better result:

1) Soft Tissue Lasers – many clinicians may employ the use one of two types of lasers to eliminate plaque bacteria in and around the roots while performing root planing.  The problem with this technique is that it is performed by feel (tactile means), therefore infectious tartar remains trapped in deep gum pockets.  Multiple treatments are usually recommended, adding to the overall cost and inconvenience.  In addition, the literature has demonstrated little to no benefit for this technique.  The cost vs. value may not be justified.

2) Local Delivery Antimicrobials – there is a variety of different adjunctive products called LDA’s (local delivery antimicrobials) which a clinician can employ in an attempt to enhance the result of root planing.  The idea is to root plane as well as possible (no objective end point), then place an LDA into the pocket.  The available LDA’s are Arestin, Atridox, Perio Chip, and Actisite.  The idea of all of these products is to kill bacteria in the deeper periodontal pockets.  However, the research on all of these adjunctive therapies remains unimpressive.  Results are typically temporary and cost vs. value may not be justified.

3)  Periowave - not yet available in the U.S. (still in the FDA approval stage), Periowave utilizes a non-thermal laser light combined with a photosensitizing solution designed to kill bacteria associated with gum disease when used adjunctively with root planing.  As with any of these adjunctive therapies, this technique is non-definitive and the literature is not impressive.  No endoscope is employed;  therefore tartar may remain in deep pockets.

Periodontal Surgery (Osseous, Flap, and Regenerative):

Following root planing, and the various adjunctive therapies listed above, periodontal surgery may be recommended in an attempt to eliminate periodontal pockets.   Periodontal surgery is performed in sections, or quadrants, under local anesthetic and often with the addition of oral sedation or nitrous oxide.  There are three types of periodontal surgery aimed at eliminating periodontal pockets and arresting periodontal disease.

Picture3 Picture4

pictures of periodontal surgeries described below – note the tartar on the roots following traditional root planing

Osseous periodontal surgery – gums are pealed back using a scalpel and other surgical instruments, tartar is then removed from the roots with an ultrasonic and a drill.  The bone around the teeth is then contoured with a drill as uneven bone is removed, hence the term osseous surgery.  The extra gum tissue is cut away (gums are removed as pockets are cut out).   This is also called “pocket reduction” surgery.  The gums are then sutured around the teeth in a lower position on the roots, creating recession and black triangles (gaps between the teeth).   This procedure is very aggressive, and while it works well to “eliminate periodontal pockets”, it leaves much to be desired in aesthetics, patient comfort, post operative root sensitivity, cost, inconvenience with multiple appointments, and long term results.  Research even demonstrates that in some cases patients will lose bone more rapidly following this surgery than if they had not had surgery.  Since large gaps called “black triangles” are often the result of this surgery, (as well as gum recession and long term root sensitivity), one should take caution if exploring this option.

IMG_4079

Above: Gaps, recession, and long tooth appearance as a result of osseous periodontal surgery.

Note: the same result can be seen with “pocket reduction surgery” or flap periodontal surgery.

Flap periodontal surgery - flap surgery follows root planing to allow for more complete removal of tartar from the roots, especially in deeper pockets and tricky root morphology (furcations).  This procedure is explicitly for the purpose of removing tartar left behind following traditional root planing and is not intended for recontouring the bone or promoting regeneration of any kind.  The gums may or may not be “cut away” before sutering, in an attempt to reduce periodontal pockets to a level which can more easily be maintained (cleansed) by the patient.  It is important to note that any type of gum surgery creates scar tissue, as well as recession of the gums.   The literature does not support this technique over traditional root planing for long term results and efficacy, and according to one study can actually make the condition worse, accelerating bone loss.  One should take caution if exploring this option for treatment of any of the anterior teeth (front teeth) due to the possible negative impact on appearance (aesthetics).

Minimally Invasive Regenerative Periodontal Surgery, or MIST:   by far the most impressive type of surgery for the treatment of periodontal disease.  This surgery is very similar to osseous surgery, with the added benefit of placing regenerative materials.  The regeneration material used varies based on the type of periodontal defects present, and the clinicians knowledge and experience using a particular regeneration material.  The main regeneration proteins used are Emdogain and Gem 21.  We highly recommend Dr. Tom Wilson or Dr. Steve Harrel in Dallas, Tx.