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 clinical results 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 A blood test can also be performed called F2-Isoprostane – the fee is only $15 and is offered by Cleveland Heart Lab. This really should be considered in a comprehensive panel of labs with anyone suffering any chronic inflammatory diseases.
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 and our own observations. 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 and floss picks.
Floss Pick Water Pik Ultra
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 – pastes, chewing gum, mints, candies, gels, rinses, etc (http://www.xlear.com/spry-dental-defense/).
2. Closys toothpaste and mouthrinse to control pathogen levels without killing good bacteria – Rowpar chlorine dioxide products available at Walgreens and Bartell’s (www.closys.com)
•Non-Irritating, great for sensitive mouths
•pH balanced which reduces potential for germ growth
•Kills 99% of harmful bacteria in 10 seconds
•Reduces plaque which leads to tartar
•Exceptional breath protection
3. Novamin or MI Paste for buffering and remineralization
4. Consider swishing with baking soda, water and xylitol to control pH and bacteria
4. Daily use of Periogen to keep tartar build up to a minimum between periodontal maintenance cleanings. (www.periogen.com)