by Shirley Gutkowski, RDH, BSDH
Volleying theories abound for most adjuncts used to combat periodontal disease. One group of scientists serves up a theory. An opposing group brutally spikes it back, and the serving team scrambles to recover. After a few hits, the idea again lands in the court of the defending viewpoint. Another spike by the serving team, but this time a college lab scientist gets behind the hypothesis, and, sustaining bruised wrists, rescues the data from a sandy grave. A second academic pounds statistics over the net. A researcher - funded by the big pharmaceutical company - fumbles; the theory hits the sand and bounces out of bounds. A second volley gets underway and the corporate researchers gain a point.
Scenarios like this can - and do - go on infinitely in the high-profile world of periodontal adjuncts. And when the "game" lasts 10 years or more, it's difficult to maintain interest - especially if the score is always tied or separated by a single point.
However, research has brought a vast array of beneficial products to the forefront. Some concepts are high-tech and revolutionary, while others, like the black bristle brushes by TESS and black floss by POH, are deceptively simple in their concepts. Their dark color makes these products especially practical for those patients who are squeamish about blood-tinged brushes or floss. Additionally, we have interproximal brushes, Stim-u-dentstrademark, a variety of floss, power brushes, power flossers, and water jets, to name a few. Each can be a useful adjunct to diminish risk for caries as well as periodontal disease. For more information, go to www.livingyounger.com.
Traditional methods of identifying periodontally involved pockets are hit and miss. The pocket may be in an arrested state due to past disease. Relying only on BOP and gingival index cannot determine if there is active disease at a certain site. What if a pocket doesn't bleed with probing, but is still breaking down? What if there is breakdown, but no pocket yet?
A breakthrough in the fight against active breakdown in periodontal tissue is Diamond General's Diamond Probe/Perio 2000 System. The Diamond Probe/Perio 2000 System detects sulfides, which are the byproduct of bacteria metabolizing protein remnants in the sulcus or pocket. The Diamond Probe is dual-purpose. As well as detecting sulfides, the probe itself can help facilitate accurate pocket depth readings.
Inserting the probe of the Perio 2000 System into an active pocket - one with tissue breakdown that exhibits the presence of the sulfides - alerts the clinician and patient with an audio beep. Log onto www.perio2000.com for more information.
New and exciting is the DV2 Perioscopy™ System. If the mantra, "Seeing is believing" applies to you, then this technology is just the thing. A tiny camera that utilizes miniature fiber optic imaging is mounted on the end of a probe. Placing the probe into the pocket gives the clinician a clear view - 48 times the original size up to 6 mm from the tip - of the topography of the root. Calculus rocks, fractures, and anything else on the root surface are plainly visible on a 13-inch monitor. More information on this product can be found at www.dentalview.com.
Ultrasonic inserts are a dynamic adjunct to periodontal therapy and are more important than hand instruments. The hygiene department that does not utilize this technology is under-supplied. The inserts available today truly are revolutionary. Some are as thin as a probe, some are coated with diamonds, and some have rounded end points that make treating teeth with complex root morphology easier. They come in different lengths and angles; one model even swivels at the fingertips. Ultrasonic scalers give the clinician the ultimate power to destroy periodontal and caries pathogens. The following Web site offers more helpful information about these tools: www.hu-friedy.com/PGnewsub.html, and www. parkell.com/scalerinserts.asp.
Water jets are wonderful at reducing periodontal pathogens in pockets up to six millimeters. Controversy exists over the use of water jet devices because they don't remove sticky plaque from teeth. However, studies conducted by Waterpik, the largest manufacturer of these devices, support their usefulness in reducing bleeding and inflammation. For perio purposes, the motion of the water pulsing across the opening of the sulcus/pocket creates a suction that virtually sucks out the free-floating bacteria from under the gingival crest. This action dramatically decreases the number of pathogens in the pocket.
Instructions - or lack thereof - for the proper use of water jets are perhaps responsible for some of the controversy. The tip of the water jet should be pointing directly between the teeth from the outside to the inside, apical to the contact - not directly at the pocket - for flushing. This misuse is what fueled the discussion of increased bacteremia risk for users. But using a water jet device is no more risky than using a brush or floss.
The force of a water jet device is not enough to remove the sticky biomass from the clinical crowns on teeth. This fact led clinicians to dismiss its efficacy. Now we know that the force of the water reconstructs the demographics of the plaque. It creates ghost cells, or cells that are nonfunctioning. The mass is still there, but the bacterial inhabitants are not.
Intraoral cameras have become a staple in many offices. They have evolved into a diagnostic tool that is essential to most practices. A talented hygienist can insert a periodontal probe into a pocket on the distal of a tooth on the nonoperator side and photograph it. The photo acts as a co-diagnostic tool for the patient and doctor.
Locally delivered, controlled-release medications are another adjunct at the forefront of periodontal disease therapy. It all started in the late 1980s with Actisite®, then graduated to PerioChip®. Later came Atridox® - a monotherapy. Today, we have Arestin® in our arsenal of useful adjuncts for periodontal therapy. Each medication promises reduced pathogens, decreased pocket depth, and reduced bleeding. They all share a concept: site-specific medications.
Prior to Arestin was the mix-it-yourself paste of mashed tetracycline and water, fibers impregnated with tetracycline, and dehydrated chlorhexidine chips. Arestin is the newest, easiest delivery mechanism for site-specific antibiotics. The theory of site-specific antibiotic delivery has been proven effective. It's better because it's easier.
The products' differences are in the timing of delivery as well as the medium that holds the ingredients together. Atridox is really a therapy studied as a monotherapy. The research designs did not include conventional ultrasonic debridement. Periochip is used every three months at recare appointments, while Arestin is designed to enhance the effects of debridement therapy by placing it into the affected pocket. Readers can obtain more information at www.arestin.com and at www.atridox.com.
Some periodontists recommend metronidasol delivered into the pocket via a syringe as an effective disease management tool. A small tube of Metro gel is inexpensive and comes with over 100 applications per tube.
To use Metro gel, the clinician loads a syringe with approximately 1cc of the gel and delivers it directly to the affected pockets. Arestin and PerioChip dosages are preset by the manufacturers. Atridox and the remedies assembled in the office are not specifically dosed. This raises the question about the importance of dosing when dealing with site-specific antibiotics.
None of the products tested have proven to cultivate resistant bacterial strains. Pocket delivery of antibiotics is here to stay. Making the process painless for the patient and clinician is the current research's relentless direction.
Providone iodine is proving to be quite an adjunct to periodontal debridement therapy. It has the broadest spectrum of antimicrobial activity of any substance or product you can put onto oral mucosa. One recent study showed a 50 percent increase of attachment gain one year after debridement therapy using providone iodine as the ultrasonic lavage. In the office it can be used either as part of the ultrasonic lavage at a ratio of 4:1 distilled water to 10 percent iodine or with a separate irrigator with a 50:50 blend. Patients at home can use the 10 percent providone iodine on an applicator (such as a interdental brush). No prescription is necessary.
The benefits of subgingival irrigation have been furiously debated. Circulating sulcular fluids replenish every 90 seconds, prompting many scientists to say that subgingival irrigation is a waste of time. However, results from this same recent study suggest that irrigating with providone iodine is cost effective.
However, using iodine has two major drawbacks. First, some patients are allergic to iodine, which prohibits its use. Secondly, the effectiveness of this treatment has not been widely publicized; therefore, clinicians are less likely to utilize it.
The other avenue of research for perio therapy adjuncts is the use of systemic drugs/vitamins. Dentaplex® is a multivitamin used in conjunction with therapy for periodontal disease. Product literature states that it supports periodontal health by supplying vitamins that target deficiencies common to demographic segments at risk for periodontal disease. These segments include smokers and the elderly.
The whole body
More "volleying" has occurred about the wisdom of medicating all body systems to treat what was previously thought to be a localized, site-specific infection around a small number of teeth. Clinicians did not consider the sulcus/pocket as a system that could adversely affect other areas of the body when infected with increased bacterial activity.
Researchers are finding that periodontal disease is a co-destructive factor in many systemic illnesses. For example, diabetes previously had been thought to be an instigator of periodontal disease. With completion of recent studies, it is now believed that it may be a contributing cause of adult onset diabetes rather than a result. Osteoporosis, another systemic malady, affects the bony support of the teeth. While researchers hammer out the intricacies of each and their related effects, oral health care providers still must treat periodontal disease. Regardless of the therapy's effect on other diseases, we must do our best to preserve periodontal support and teeth.
Medicating the whole body may be the way to go. Systemic enzyme suppression using doxycycline hycalate (a form of tetracycline) has been proven to reduce the level of periodontal disease by shrinking pocket depths. The presence of doxycycline hycalate not only decreases the amount of bacteria, but also decreases the activity of enzyme production.
What's interesting - and confusing - is determining the proper dose. So far, one drug addresses the systemic effects of the presence of periodontal pathogens by novel dosing of a known antibiotic. That is Periostat, the only FDA approved drug for enzyme suppression made by CollaGenex. When used in subclinical doses, Periostat has a significant therapeutic effect that directly suppresses those enzymes that contribute to tissue and bone destruction. Scientists at CollaGenex are finding that this novel dose of doxycycline may have applications for use in other autoimmune breakdown diseases such as rheumatoid arthritis. For more information, go to www.colla genex.com/newhtml/index.html.
This is a thorough but not an exhaustive list of adjuncts and adjunctive therapies. Information is readily available in this and other dental hygiene periodicals, as well as the Internet. Hygienists are fortunate indeed to have such a vast array of products available to help our patients achieve oral and systemic health.
The author wishes to thank Maria Perno Goldie, RDH, MS; Dr. Larry Burnett; Dr. Neil Gotterher; Kristy Menage Berney, RDH; Don Musinski, PhD; Dr. Robert E. Reed; and Carol Jahn, RDH, MS, for their assistance with fact checking. A very special thanks to Anne Guignon, RDH, MPH for her valuable help and support.
Shirley Gutkowski, RDH, BSDH, has been a full-time practicing dental hygienist in Madison, Wis., since 1986. A widely published author, Ms. Gutkowski also speaks to groups through Cross Links Presentations. She can be contacted by email at [email protected].