PerioEndoscopy and Integrative Care – Case Studies for discussion:
We have created this blog page to post pics and comprehensive information on actual PerioPeak case studies for the purpose of more in-depth clinical education and sharing of knowledge. Professionals and patients are welcome and encouraged to post here.
I will be seeing this patient soon traveling in from out of state. He has had blind root planing 4 times in past 18 months. Twice with the periodontist. He was told he has “rough roots”. While he was told to get a “physical”, he was not given a list of labs to check for causal risk factors such as D deficiency or other. I have requested comprehensive labs on him before treating him in April. I will also run a full genetic panel and pathogen test since no one has done this. This pt has hx of ortho, excellent diet, BMI wnl, no family hx of anything, has NG. He’s only 32. Pockets are gen 5-6mm with gen. BOP and severe infl as you can see, gen early to moderate horizontal bone loss on x-rays. We expect to find residual ortho cement sub-g in many areas. He does have seasonal allergies and there are mouth breathing and myofunctional issues as part of overall risk factors (bruxism as well). He is lactose intolerant and takes a high potency multivitamin daily. I have seen cases like this in the past (non-responsive, hyper-inflammatory), in my experience it always seems to be young males who are “type A” personality, there is also a genetic component. His mom has had hx of perio issues, father HBP but is overweight. Rarely do these individuals have pathogens. We will be looking closely into all systemic issues, including adrenals. Comments? I will post test results and findings next month once I have all the data.
Update – here is what we determined: As I suspected this patients bacteria profile is very clean, no pathogens. His genetic profile is positive for IL6, TNF alpha and IL17A polymorphism (he has hyper-inflammatory immune response). He was diagnosed with severe vitamin D deficiency and is now taking high doses. Upon clinical exam chronic mouth breathing was determined (along with tongue thrusting and clenching), with suspected sleep apnea. We referred him to the ENT right away for severe obstructive airway issues. We recommend he continue on Periostat and high doses of D3.
Could your chronic periodontal disease involve viruses?
Periodontal diseases can involve bacteria and/or viruses initiating chronic inflammation and ensuing tissue and bone destruction. Patients with history of herpes simplex virus (HSV) or Epstein Barr virus (EBV) are especially high risk for the presence of these putative pathogens. We do not currently have oral salivary DNA tests to either confirm or refute the presence of viruses in the risk factor assessment of active periodontitis, but blood tests can be performed for the presence of antibodies. To date the only way to combat oral viruses is to have definitive periodontal treatment to eliminate periodontal pockets and utilize a diluted bleach solution at home (1/20 bleach with water).
Biology and Pathogenesis of Cytomegalovirus in Periodontal Disease:
Periodontol 2000. 2014 Feb;64(1):40-56. doi: 10.1111/j.1600-0757.2012.00448.x.
Biology and pathogenesis of cytomegalovirus in periodontal disease.
Contreras A, Botero JE, Slots J.
Human periodontitis is associated with a wide range of bacteria and viruses and with complex innate and adaptive immune responses. Porphyromonas gingivalis, Tannerella forsythia, Aggregatibacter actinomycetemcomitans, Treponema denticola, cytomegalovirus and other herpesviruses are major suspected pathogens of periodontitis, and a combined herpesvirus-bacterial periodontal infection can potentially explain major clinical features of the disease. Cytomegalovirus infects periodontal macrophages and T-cells and elicits a release of interleukin-1β and tumor necrosis factor-α. These proinflammatory cytokines play an important role in the host defense against the virus, but they also have the potential to induce alveolar bone resorption and loss of periodontal ligament. Gingival fibroblasts infected with cytomegalovirus also exhibit diminished collagen production and release of an increased level of matrix metalloproteinases. This article reviews innate and adaptive immunity to cytomegalovirus and suggests that immune responses towards cytomegalovirus can play roles in controlling, as well as in exacerbating, destructive periodontal disease.
We have always had an “open door” clinic policy for Perio-endoscopy/RPE℠ observation. With 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 thousands of hours of 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 perio-endoscopy/RPE observation (shadowing).
We welcome any clinician to come observe an actual perio-endoscopy/RPE℠ case. You will be forever changed after spending a day shadowing Judy Carroll, RDH or one of her trained specialists.
Students learning excellent perio-endoscopy skills in two days (basic certification).
We teach what we call a “fast track” perio-endoscopy 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.
What is the “Healthy Gums for Life” protocol and what makes this methodology different? It’s the most definitive and comprehensive treatment protocol offered anywhere in the world. 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. Too often, periodontal patients proceed with laser surgery, perioscopy, traditional surgery and/or multiple deep cleanings without ever addressing all the risk factors creating chronic inflammatory periodontal disease. Their disease returns a year or less later and continues…we call this the perio-merri-go-round. There is a better way.
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 to help determine underlying issues contributing to 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 overall clinical outcomes are enhanced. This is not a one size fits all program, and men and women can have different issues. We strongly encourage integrative care with a medical doctor or naturopathic doctor of the patients choosing.
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 periodontal medicine” since we are not guessing about virulent pathogen involvement, thus we can pinpoint the appropriate short term antibiotic for the infection. 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 pathogen 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 8 inflammatory gene polymorphisms (Celsus One) – these genetic polymorphisms are very important risk factors to determine for a person with current periodontal disease, heart disease, or diabetes, or for someone with family history of these diseases. Knowing this information provides valuable understanding about host response and overall risk. Once this information is known, it empowers both the professional and the patient to create optimal therapy strategies moving forward to control potential hyper-inflammation and chronic disease. There are many ways to down-regulate 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 Celsus One report – this patient is high risk for chronic inflammatory periodontal disease due to a polymorphism of IL1, IL6, TNF-alpha and IL17A , which means he potentially has a “hyper-inflammatory” immune response when these genes express due to lifestyle and parafunctions (diet, smoking, clenching, sleep apnea, mouth breathing, tongue thrusting), deficiencies, stress and/or presence of bacteria, viruses or other pathogens (fungus and parasites). Detailed information can be learned on the report for CVD and diabetes risk as well. We have found that individuals with auto-immune type diseases such as Lupus, RA and MS tend to score positive for polymorphisms of the inflammatory genes. The results of this test, combined with the results of the pathogen test (along with any systemic tests we have had our client complete), help the decision making process moving forward; integrated care is provided with the physician or other medical professional. Again, this is individualized periodontal medicine, not a one size fits all method. For example, while these polymorphisms for hyper-inflammatory response put 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 important information provided in the bacteria test, we can come together with the physician or cardiologist (for those individuals with current CVD) to form a long term therapy strategy.
Host modulated therapy – very important. A very effective medication for chronic inflammatory periodontal disease has been publicly available for the past 18 years – Periostat (non-antibiotic low dose of doxycycline – 20mg). Periostat works as an anti-inflammatory, not an antibiotic. It effectively reduces bone destroying cells and harmful collagen destroying enzymes. It helps to “reset” the inflammatory response, which in many individuals with chronic periodontitis is “accentuated and inappropriate”. In addition, Periostat changes the oral environment to be less conducive to pathogen survival by creating a more oxygenated environment. Periostat slows or stops the progression of periodontal disease when used adjunctively with active periodontal therapy. Periostat will actually activate bone building cells (osteoblasts) when used with proper definitive periodontal therapy. This medication has been published extensively in the periodontal and medical literature over the past 25+ 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 and severity. 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 cardio-protective properties. 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).
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. Many patients with this habit are also “tongue tied” and require a lingual frenectomy to free the tongue so they can swallow correctly.
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.
Home Care: at PerioPeak we teach our patients the very latest in home care methods and products to use based on our many years of observation and research; this part of our program has become very detailed and specific to each patients needs (individualized periodontal care) and is an important aspect of our comprehensive methodology for long term periodontal health management.
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 – 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.
Department of Periodontology, College of Dentistry, University of Tennessee Health Science Center, Memphis, Tennessee, USA.
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.
Novel roles of vitamin D in disease: What is new in 2011?
Department of Internal Medicine, Medical School, University of Ioannina, Ioannina, Greece; Department of Child Health, Medical School, University of Ioannina, Ioannina, Greece.
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.
A review of the critical role of vitamin D in the functioning of the immune system and the clinical implications of vitamin D deficiency.
University of Alberta, Edmonton, Alberta, Canada. firstname.lastname@example.org
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.
Modern concepts in the diagnosis and treatment of vitamin D deficiency and its clinical consequences.
University of Virginia Health System, Charlottesvill, VA, USA. email@example.com
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 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.
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.
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?
Tooth loss in periodontally treated patients: a long-term study of periodontal disease and root caries.
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
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.
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.
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.
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.
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
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℠.
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.
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.