RDH UOR Upsetting the Underworld of Biofilms - INeedCE.com

UPSETTING
 THE
 UNDERWORLD
 OF
 BIOFILM
 WITH
 SALIVARY
 
DIAGNOSTICS
 AND
 SUBGINGIVAL
 AIR
 POLISHING
 

Karen
 Davis,
 RDH,
 BSDH
 


 
Three
 concepts
 to
 narrow
 the
 focus:
 

1. Biofilm
 is
 the
 enemy
 
2. Saliva
 is
 a
 powerful
 tool
 
3. Time
 is
 a
 precious
 commodity
 

1.
  BIOFILM
 IS
 THE
 ENEMY!
 


 
Calculus
 is
 the
 partner,
 but
 biofilm
 is
 the
 culprit.
 
 Its
 thorough
 removal
 is
 paramount
 to
 
establishing
 and
 maintaining
 periodontal
 health.
 

Keystone-­‐Pathogen
 Hypothesis
 (KPH)
 
 &
 Polymicrobial
 Synergy
 &
 Dysbiosis
 (PSD)
 

A
 synergistic
 but
 imbalanced
 community
 of
 microorganisms
 causes
 periodontal
 diseases.
 
 
Different
 species
 have
 different
 roles
 and
 “keystone
 pathogens”
 trigger
 inflammation
 by
 
modulating
 the
 host
 response
 and
 strengthening
 the
 biofilm
 with
 accessory
 
microorganisms.
 
 It
 is
 uncertain
 whether
 periodontal
 pathogens
 initiate
 periodontitis,
 or
 
whether
 the
 response
 of
 the
 immune
 system
 perpetuates
 inflammation
 and
 favors
 
pathogenic
 growth.
 

P.
 gingivalis
 may
 be
 a
 very
 low
 percentage
 of
 the
 biofilm;
 yet
 can
 trigger
 an
 aggressive
 
periodontal
 destruction.
 

Restoration
 of
 homeostasis
 in
 diseased
 sites
 is
 a
 promising
 opportunity
 for
 disease
 
management.
 
 
 

Opportunities
 to
 alter
 the
 host
 response:
 

• Reduction
 of
 systemic
 inflammation
 
Diet
 modifications
 &
 increase
 of
 Omega-­‐3
 fatty
 acids,
 stress
 management,
 regular
 

exercise,
 and
 tobacco
 cessation
 

• Adjuncts
 of
 anti-­‐inflammatory,
 antibacterial
 agents
 and
 probiotics
 
Periosciences®
 –
 topical
 anti-­‐inflammatory
 &
 anti-­‐bacterial
 
 
Colgate
 Total®
 with
 Triclosan
 -­‐
 anti-­‐inflammatory
 &
 anti-­‐bacterial
 
 
 
 

PerioBalance®
 &
 Oragenics®
 

Lactobacillus
 reuteri
 reduced
 risk
 for
 disease
 progression.
 

 
 
  Need
 for
 additional
 surgery
 outcome
 measures
 were
 
 
 
 


 
 
  significantly
 better
 when
 L.
 reuteri
 lozenges
 were
 used
 as
 an
 
 
 

 
 
  adjunct
 to
 SRP,
 compared
 to
 SRP
 +
 
p   lacebo.
 
 

Karen Davis, RDH, BSDH * Cutting Edge Concepts *[email protected] 1
 
646 Goodwin Drive Richardson, TX * 972-669-1555 * [email protected]

 
 
  Significantly
 more
 pocket
 depth
 reduction
 &
 attachment
 gain
 
 
 

 
 
  in
 moderate
 &
 deep
 pockets;
 and
 more
 P.
 gingivitis
 reduction
 
 
 

 
 
  in
 the
 SRP
 +
 probiotic
 group.
 
 

 
 
 
 
  Journal
 of
 Clinical
 Periodontology
 2008
 

• Dismantle
 &
 destroy
 the
 biofilm!
 

 

Biofilm
 Basics:
 
 (Dimensions
 of
 Dental
 Hygiene
 2003)
 
• Mechanical
 debridement
 is
 essential
 
• Bacteria
 in
 biofilms
 are
 more
 resistant
 to
 antimicrobials
 than
 planktonic
 bacteria
 
• Calculus
 is
 not
 the
 etiology.
 
 It
 must
 be
 removed
 because
 it
 is
 a
 haven
 to
 the
 etiology
 
–
 biofilm
 
• Local
 &
 systemic
 antimicrobials
 are
 adjuncts
 only
 

Goals:
 
Eradiate
 as
 much
 biofilm
 as
 possible
 
Do
 so
 as
 comfortably
 as
 possible
 
Do
 so
 as
 efficiently
 as
 possible
 


 
Glycine
 powder
 air
 polishing
 is
 safe
 and
 causes
 less
 gingival
 erosion
 than
 hand
 
instrumentation
 and
 sodium
 bicarbonate
 air-­‐polishing
 


 
  Journal
 of
 Clinical
 Periodontology
 2008
 

A
 Paradigm
 Shift
 In
 Mechanical
 Biofilm
 Management?
 Subgingival
 Air
 Polishing:
 A
 
New
 Way
 to
 Improve
 Mechanical
 Biofilm
 Management
 in
 the
 Dental
 Practice
 

Quintessence
 International
 2013
 

  Summary:
 

• Air
 polishing
 devices
 have
 shown
 to
 be
 efficient
 in
 removing
 both
 sub
 and
 
supragingival
 biofilm
 and
 stains
 
 

• The
 new
 generation
 of
 powders
 and
 devices
 with
 subgingival
 nozzles
 provide
 better
 
access
 to
 subgingival
 and
 interdental
 areas
 
 

• In
 shallow
 pockets
 up
 to
 4
 mm
 and
 in
 deeper
 pockets
 ≥
 5
 mm,
 air
 polishing
 removes
 
biofilm
 significantly
 more
 efficiently
 than
 hand
 curettes
 
 

• Full-­‐mouth
 glycine
 powder
 air
 polishing
 results
 in
 a
 significantly
 decreased
 load
 of
 
Porphyromonas
 gingivalis
 in
 the
 oral
 cavity
 
 

• Subgingival
 biofilm
 removal
 with
 air
 polishing
 is
 considerably
 faster
 than
 hand
 
instrumentation
 or
 ultrasonics
 
 

• Glycine-­‐based
 air
 polishing
 is
 perceived
 as
 more
 comfortable
 by
 the
 patients
 than
 
hand
 instrumentation
 or
 ultrasonics
 
 

• Subgingival
 air
 polishing
 with
 glycine-­‐based
 powder
 is
 safe
 if
 used
 as
 per
 
 

  recommendation
 

 

 

Karen Davis, RDH, BSDH * Cutting Edge Concepts *[email protected] 2
 
646 Goodwin Drive Richardson, TX * 972-669-1555 * [email protected]

For
 exposed
 roots,
 cleaning
 with
 sodium
 bicarbonate
 powder
 cannot
 be
 recommended.
 
 
Less
 abrasive
 glycine
 powder
 however,
 demonstrated
 non-­‐critical
 substance
 loss
 of
 the
 
tooth
 surface.
 


 
  Journal
 of
 Periodontology
 2014
 

Treatment
 of
 peri-­‐Implantitis
 using
 air-­‐polishing
 technology
 with
 low-­‐abrasive
 erythritol
 +
 
chlorhexidine
 powder
 had
 significantly
 higher
 reductions
 on
 BOP
 than
 mechanical
 
debridement.
 
 


 
  Journal
 of
 Clinical
 Periodontology
 2011
 

Seven
 implant
 instruments
 were
 tested
 in
 vivo
 for
 biofilm
 removal
 on
 titanium
 disks:
 1)
 
manual
 plastic
 instruments,
 2)
 manual
 carbon
 fiber-­‐reinforced
 plastic
 (CFRP)
 curette,
 3)
 
sonic-­‐driven
 prophylaxis
 brush,
 4)
 rotating
 rubber
 cup
 with
 prophylaxis
 paste,
 5)
 sonic-­‐
driven
 polyether
 ether
 ketone
 (PEEK)
 plastic
 tip,
 6)
 ultrasonic-­‐driven
 PEEK
 plastic
 tip
 &
 7)
 
air
 polishing
 with
 amino
 acid
 glycine
 powder.
 
 

Results:
 Effectiveness
 of
 plastic
 curette
 significantly
 lower
 that
 those
 of
 all
 machine-­‐driven
 
instruments.
 
 The
 rubber
 cup
 provided
 less
 cleaning
 effectiveness
 compared
 to
 the
 
ultrasonic
 PEEK
 plastic
 tip
 and
 air
 polishing.
 
 Superior
 results,
 with
 less
 than
 4%
 of
 the
 
biofilm
 remaining,
 were
 obtained
 with
 oscillating
 PEEK
 plastic
 tips,
 and
 air
 polishing.
 


 
  International
 Journal
 of
 Oral
 &
 Maxillofacial
 Implants
 2014
 
 
 


 

Additional
 Air
 Polishing
 Research:
 

www.Hu-­‐Friedy.com/HFEMS
 >
 Clinical
 Evidence
 Guide
 


 

Devices
 for
 Subgingival
 Air
 Polishing
 with
 Low-­‐Abrasive
 Powders:
 
• Hu-­‐Friedy
 EMS
 AirFlow
 Master
 Piezon®
 -­‐
 combination
 piezon
 and
 air
 polishing
 
unit
 with
 interchangeable
 nozzles
 and
 powder
 chambers
 for
 supragingival
 air
 
polishing
 with
 sodium
 bicarbonate
 or
 glycine
 powder
 &
 subgingival
 air
 polishing
 
with
 glycine.
 
• Hu-­‐Friedy
 EMS
 AirFlow®
 Handy
 -­‐
 portable
 air
 polishing
 unit
 for
 supragingival
 air
 
polishing
 with
 sodium
 bicarbonate
 or
 glycine.
 
 Subgingival
 up
 to
 4
 mm
 with
 glycine.
 
 
• Hu-­‐Friedy
 EMS
 Air
 Flow
 Handy
 Perio®
 -­‐
 portable
 air
 polishing
 unit
 for
 
subgingival
 air
 polishing
 for
 pockets
 deeper
 than
 4mm.
 Glycine.
 
• Acteon
 Satelec
 Air-­‐N-­‐Go®
 -­‐
 Interchangeable
 portable
 unit
 for
 supragingival
 air
 
polishing
 with
 sodium
 bicarbonate
 or
 calcium
 carbonate
 powder
 &
 subgingival
 air
 
polishing
 with.
 
• Coltene
 Biosonic
 Suvi®-­‐
 combination
 ultrasonic
 and
 air
 polishing
 unit
 for
 
supragingival
 air
 polishing
 with
 sodium
 bicarbonate
 and
 subgingival
 air
 polishing
 
with
 glycine.
 


 

Karen Davis, RDH, BSDH * Cutting Edge Concepts *[email protected] 3
 
646 Goodwin Drive Richardson, TX * 972-669-1555 * [email protected]

Low-­‐Abrasive
 Powders
 Safe
 for
 Subgingival
 Air
 Polishing:
 
• Glycine
 25g
 
• Erythritol
 14g
 –
 hopefully
 available
 in
 the
 U.S.
 soon
 


 

Contraindications:
 
• Communicable
 diseases
 
• Respiratory
 diseases
 
• Immunocompromised
 (clinical
 judgment)
 


 

Clinical
 Protocols
 for
 Biofilm
 Management
 with
 Subgingival
 Air
 Polishing
 
(Optional:
 Sodium
 bicarbonate
 air
 polish
 for
 stain
 removal
 on
 tooth
 surfaces)
 

1. Glycine
 air
 polish
 for
 supra
 and
 subgingival
 biofilm
 removal
 (11/12
 explorer)
 
2. Power
 instrument
 for
 supragingival
 stain
 and
 calculus
 removal
 &
 subgingival
 

calculus
 removal.
 
 
3. Site-­‐specific
 instrumentation
 with
 hand
 instruments
 
 

 

Paradigm
 Shift:
 Biofilm
 Removal
 First!
 

2.
  SALIVA
 IS
 A
 POWERFUL
 TOOL
 


 

What…identify
 the
 pathogens?
 
After
 invading
 the
 vessel
 wall
 oral
 pathogens
 trigger
 an
 inflammatory
 response
 
contributing
 to
 endothelial
 dysfunction
 


 
  Current
 Cardiology
 Review
 2014
 

Longitudinal
 improvement
 in
 clinical
 and
 microbial
 periodontal
 status
 is
 related
 to
 a
 
decreased
 rate
 of
 carotid
 artery
 IMT
 (Intima-­‐medial
 thickness)
 progression
 at
 3-­‐year
 
average
 follow-­‐up.
 
 


 
  Journal
 of
 the
 American
 Heart
 Association
 2013
 

 

Periodontal
 pathogen
 Fusobacterium
 nucleatum
 (Fn)
 invades
 epithelial
 tissue
 and
 
subsequent
 endothelial
 cells
 and
 increases
 permeability
 of
 the
 endothelial
 wall,
 enabling
 
penetration
 of
 additional
 pathogens
 that
 contribute
 to
 systemic
 inflammation.
 


 
  Molecular
 Microbiology
 2011
 

A
 correlation
 was
 established
 between
 putative
 bacteria
 contributing
 to
 arterial
 plaques
 
and
 species
 associated
 with
 periodontal
 disease.
 


 
  Indian
 Journal
 of
 Pathology
 &
 Microbiology
 2015
 

Karen Davis, RDH, BSDH * Cutting Edge Concepts *[email protected] 4
 
646 Goodwin Drive Richardson, TX * 972-669-1555 * [email protected]

P.
 gingivalis
 was
 found
 at
 a
 frequency
 of
 34.5%
 in
 patients
 with
 chronic
 periodontitis
 and
 
clinical
 isolates
 were
 highly
 sensitive
 to
 metronidazole
 and
 tetracycline.
 


 
  Acta
 Odontologica
 Latinoamericana
 2014
 

P.
 gingivalis
 is
 an
 aggressive
 periodontopathogen,
 capable
 of
 penetrating
 and
 surviving
 
within
 the
 host
 cells
 due
 to
 several
 motility
 and
 invasion
 factors,
 and
 it
 also
 produces
 by-­‐
products
 that
 are
 toxic
 to
 oral
 tissues.
 


 
  Dimensions
 of
 Dental
 Hygiene
 Digest
 2013
 
 

Certain
 periodontal
 bacteria,
 such
 as
 T.
 denticola,
 T.
 forsythia,
 and
 Aggregatibacter
 
actinomycetemcomitans
 are
 strongly
 associated
 with
 destructive
 inflammatory
 responses
 
and
 additionally
 subvert
 the
 host
 response
 in
 ways
 that
 could,
 at
 least
 in
 principle,
 enhance
 
the
 survival
 of
 also
 bystander
 species.
 


 
  Trends
 In
 Immunology
 2015
 

Oral
 DNA
 MyPerioPath®
 
 
Prior
 to
 therapy
 for
 determination
 of
 pathogens
 and
 threshold
 levels
 

Following
 therapy
 to
 assess
 reduction/elimination
 of
 pathogens
 

D0417
 Collection
 and
 preparation
 of
 saliva
 sample
 for
 laboratory
 diagnostic
 testing
 

Why
 look
 at
 genetic
 markers?
 
Approximately
 50%
 of
 the
 differences
 in
 severity
 of
 periodontal
 disease
 among
 adults
 are
 
due
 to
 genetics
 


 
  Journal
 of
 Periodontology
 1991,
 2000
 

Meta-­‐Analyses
 and
 systematic
 reviews
 support
 a
 significant
 association
 between
 IL-­‐1
 gene
 
variations
 and
 periodontitis.
 
 


  Journal
 of
 Clinical
 Periodontology
 2008,
 Quintessence
 International
 2010,
 
 

 
  Journal
 of
 Periodontology
 2012
 
 

 

IL-­‐1
 genotype
 positive
 patients
 require
 more
 treatment
 to
 maintain
 health
 compared
 to
 IL-­‐
genotype
 negative
 patients.
 


 
  Journal
 of
 Clinical
 Periodontology
 2008
 

According
 to
 Andreiotelli,
 et
 al,
 the
 diagnostic
 value
 of
 Interleukin-­‐1
 genotyping
 and
 genetic
 tests
 
for
 peri-­‐implantitis
 should
 be
 reconsidered
 before
 treatment
 planning,
 regimens
 and
 maintenance
 

in
 implant
 dentistry.
 
 The
 excessive
 or
 inadequate
 host
 inflammatory
 response
 might
 be
 critical
 to
 

the
 pathogenesis
 of
 peri-­‐implant
 disease.
 


 
  Quintessence
 International
 2008
 

Michigan
 Personalized
 Prevention
 Study
 (MPPS)
 

 
  Journal
 of
 Dental
 Research
 2013
 

5000+
 patients.
 
 Evaluated
 16
 years
 for
 3
 risk
 factors
 for
 periodontal
 disease:
 smoking,
 
diabetes,
 and
 IL-­‐1
 genotype
 

Karen Davis, RDH, BSDH * Cutting Edge Concepts *[email protected] 5
 
646 Goodwin Drive Richardson, TX * 972-669-1555 * [email protected]

  Results:
 


  47%
 of
 the
 patients
 had
 none
 of
 the
 risk
 factors
 


 
  53%
 had
 at
 least
 one
 of
 the
 risk
 factors
 

  For
 patients
 with
 no
 risk
 factors,
 2
 prophylaxes
 per
 year
 did
 not
 result
 in
 significant
 

  reduction
 of
 tooth
 loss
 compared
 to
 1.
 


  For
 patient
 with
 1
 or
 more
 risk
 factors,
 2
 prophylaxes
 added
 significant
 value
 in
 

  reducing
 the
 risk
 of
 tooth
 loss.
 


  For
 patients
 with
 2
 or
 more
 risk
 factors,
 2
 prophylaxes
 were
 not
 adequate
 

Oral
 DNA
 MyPerioID®
 IL-­‐6
 genotype:
 High,
 Moderate
 or
 Low
 Risk
 for
 Periodontal
 Disease
 

Oral
 DNA
 Celsius
 One
 test™
 genetic
 markers
 related
 to
 inflammatory
 response
 

Interleukin
 Genetics
 PerioPredict®
 IL-­‐1
 genotype
 positive
 or
 negative
 

D0421
 Genetic
 Test
 For
 Susceptibility
 To
 Oral
 Diseases
 –
 Once
 in
 a
 lifetime
 test
 

3.
  TIME
 IS
 A
 PRECIOUS
 COMMODITY!
 


 

Biofilm
 Management
  Traditional
  Biofilm
 
(Prophylaxis/PM) Hygiene
  Management
Prophy/PM Prophy/PM

Screening/Data
 Collection
 7
 min. 12
 min.

Communication/Treatment
 
 5
 min. 12
 min.
Enrollment

Clinical
 Treatment 38
 min. 26
 min.

Examination
 7
 min. 7
 min.

Hand
 Off
 &
 Disinfect
 Room
 3
 min. 3
 min.
 

60
 min. 60
 min.


 
Total
 Minutes
 Saved
 for
 Biofilm
 Removal:
 ~10
 

Increased
 Time
 for
 Data
 Collection,
 Communication
 &
 Additional
 Services
 

What
 would
 you
 do
 with
 10
 extra
 minutes
 with
 your
 patients?
 

Karen Davis, RDH, BSDH * Cutting Edge Concepts *[email protected] 6
 
646 Goodwin Drive Richardson, TX * 972-669-1555 * [email protected]

IMPLEMENTATION
 STRATEGIES:
 
• Assess
 the
 Evidence
 
• Identify
 objections
 
• Examine
 risk
 versus
 benefits
 
• Educate
 team
 
• Educate
 patients
 


 

 

NOTES:
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Never
 accept
 the
 following
 logic:
 we’re
 doing
 it
 this
 way
 because
 that’s
 

how
 we’ve
 always
 done
 it,
 or
 we’re
 not
 doing
 it
 because
 we’ve
 never
 done
 it…
 

Barry
 Gibbons,
 Former
 CEO,
 Burger
 King
 

Karen Davis, RDH, BSDH * Cutting Edge Concepts *[email protected] 7
 
646 Goodwin Drive Richardson, TX * 972-669-1555 * [email protected]